Unemployment and suicidal behaviour: A review of the literature

Sot. Sci. Med. Vol. 19. No. 2, pp. 93-115, Printed in Great Britain

0277-9536184 $3.00 + 0.00 Pergamon Press Ltd

1984

UNEMPLOYMENT A REVIEW

AND SUICIDAL BEHAVIOUR: OF THE LITERATURE* STEPHEN PLAIT

MRC Unit for Epidemiological Studies in Psychiatry, University Department of Psychiatry, Edinburgh Hospital, Momingside Park, Edinburgh EHlO SHF, Scotland

Royal

Abstract-In order to provide a framework for reviewing the voluminous literature on unemployment and suicidal behaviour, the author distinguishes between two categories of deliberately self-harmful act: those with fatal outcome (suicide) and those with non-fatal outcome (parasuicide); and differentiates four major types pf quantitative research report: individual-cross-sectional; aggregate-cross-sectional; individuallongitudinal; and aggregate-longitudinal. Methodological issues and empirical research findings are discussed separately for each type of study and each category of deliberate self-harm. Cross-sectional individual studies reveal that significantly more parasuicides and suicides are unemployed than would be expected among general population samples. Likewise, parasuicide and suicide rates among the unemployed are always considerably higher than among the employed. Aggregate-cross-sectional studies provide no evidence of a consistent relationship between unemployment and completed suicide, but a significant geographical association between unemployment and parasuicide was found. Results from all but one of the individual longitudinal studies point to significantly more unemployment, job instability and occupational problems among suicides compared to non-suicides. The

aggregate longitudinal analyses reveal a significant positive association between unemployment and suicide in the United States of America and some European countries. The negative relationship in Great Britain during the 1960s and early 1970s has been shown to result from a unique decline in suicide rates due to the unavailability of the most common method of suicide. However, despite the firm evidence of an association between unemployment and suicidal behaviour, the nature of this association remains highly problematic. On the basis of the available data, the author suggests that macro-economic conditions, although not directly influencing the suicide rate, may nevertheless constitute an important antecedent variable in the causal chain leading to self-harmful behaviour. Further empirical research based on a longitudinal design is recommeded as a matter of urgency so that a more definitive assessment of the aetiological significance of unemployment in parasuicide may be made.

Frank Allaun, M.P.: “Has [the Secretary of State for the Home Department, Mr David Mellor] read the recent report of a young worker with a wife and

years. Falret [2] contended that suicide rates tend to rise during periods of rapid social change and in times of economic depression. By the time that Durkheim wrote his seminal work on suicide, he believed that Falret’s contention had been confirmed to such an extent that he was able to write: “It is a well-known fact that economic crises have an aggravating effect on the suicidal tendency” [3]. However, many contemporary researchers have tended to question Durkheim’s assumption. The recent heated exchange between Brenner [4, 51, Gravelle et al. [6] and Eyer [7-91, demonstrates that the issue is far from being resolved. So what is the evidence on the association between unemployment (nowadays the most commonly used indicator of economic recession) and ‘the suicidal tendency? If there is any such association, is it possible to postulate a direct causal link? If unemployment is the new ‘great plague’, then, as a Lancet editorial puts it colourfully, “we need to know the enemy before we choose the weapon-is it the uncertain status of unemployment, the behavioural reaction (more drink, more cigarettes) to being without a job, or the fact of relative poverty. . . or is it some complex interaction of all three?” [IO]. In other words, what is it about unemployment that is suicidogenic? Answers to these questions are needed urgently, in view of the extremely high levels of unemployment which prevail not only in the U.K. but throughout Europe and also in the United States.

baby who hanged himself, according to the coroner, because he had been out of work for nine months? Does he relise the growing number of tragedies resulting from the spread of unemployment?” David Mellor, M.P.: “There is no reason to link unemployment with suicide. I should have thought that it would not be seemly to have party disputations on why people commit suicide” [I]. INTRODUCTION

With the inexorable rise of unemployment over the past decade in Europe and the United States to levels unknown since the depression of the 193Os, social scientists have once again turned their attention towards the delineation and measurement of its impact upon society. Among the most extreme behavioural responses to the experience of unemployment is the act, or even the serious contemplation, of suicide. The existence and nature of any association between the economic climate and suicidal behaviour has been the subject of debate for more than 150 *This is a considerably revised version of a paper presented to the WHO Workshoo on Health Policv in Relation to Unemployment in the’community, Nufiield Centre for Health Services Studies, Leeds 13-15 December 1982 SS.M

19 2-a

93

91

STEPHEN PLATT

As Gravelle et al. [6] note. Brenner’s conclusion [5] that fluctuations in mortality are largely explained by current and lagged unemployment rates “is important because it suggests that the social costs of unemployment may be higher than had previously been thought“. If Brenner is correct, this may be a rather phlegmatic British understatement. On aggregate, the statistical associations which Brenner derives from a multivatiate regression analysis reveal that a single percent increase in the unemployment rate in the United States, if maintained over 6 years, could be associated with 36,890 additional deaths and a rise in indicators of social morbidity [I 11. ‘THE SUICIDAL

TENDENCY’: DISTINCTIONS DEFINITIONS

AND

In the following review two types of suicidal behaviour (defined as a deliberately self-harmful act) will be distinguished: those with fatal outcome (i.e. suicide) and those with non-fatal outcome [once termed ‘attempted suicide’ but nowadays more commonly referred to as ‘parasuicide’ [12] or ‘deliberate self-harm’ (DSH)]. Since each study tends to adopt a somewhat idiosyncratic nominal definition of suicide/parasuicide, and it is not unusual to find operational and nominal definitions at variance with each other within-the same study, comparisons between different investigators are thereby made more problematic. Nevertheless, a common element in both types of suicidal behaviour is the presence of a deliberate intention to endanger the integrity of the bilogical organism and influence the potentiality of further conscious experience. Shneidman [ 131 uses the term ‘cessation’ to refer to the final ending of consciousness, and describes four basic orientations which the individual may adopt towards his own demise: intentioned (where “the individual plays a direct and conscious role in his own demise”), subintentioned (“the individual plays an indirect, covert, partial or unconscious role. .“), unintentioned (“the person psychologically plays no significant role. .“) and contraintentioned (“an individual who uses the semantic blanket of ‘Suicide!’ with a conscious absence of any lethal intention”). Although some ‘suicides’ will be unintentioned (‘accidents’), most are probably cessation-intentioned, while the majority of acts of deliberate self-harm are cessationunintentioned or cessation-contraintentioned. This is not, of course, to deny that some parasuicides are cessation-(sub) intentioned [14]. However, as Stengel and Cook [I51 pointed out in their influential monograph 25 years ago, the great majority of patients usually described as ‘attempted suicide’ do not have an unequivocal wish to die. While the variety and complexity of motivation for ‘attempted suicide’ has been illustrated by a number of authors [16], most would probably agree with Kessel’s view [14] that what is more commonly sought is not the cessation of consciousness but its interruption, defined by Shneidman [ 131 as “the stopping of consciousness with the actuality, and usually the expectation, of further conscious experience. It is a kind of temporary cessation”. Stengel and Cook [ 151 were the first to draw a clear distinction between suicide and parasuicide (‘at-

tempted suicide‘). Decrying the traditional conceptualisation of attempted suicides as merely failed suicides, they not only pointed to the complexity of motivation in non-fatal suicidal behaviour but also identified important epidemiological differences between attempted suicide and completed suicide populations. Subsequent researchers have maintained the distinction between the two types of behaviour [ 171. whilst noting that they are related: “two separate. but overlapping, populations” [ 181. There is abundant empirical evidence of epidemiological differences between suicide and parasuicide populations [19] but less widespread consensus on the extent to which the two behaviour types are differentiated on nonepidemiological variables. However, research evidence is available which suggests characteristic differences in relation to the methods of self-harm which have been used. clinical aspects (e.g. psychiatric diagnosis, personality diagnosis, previous psychiatric treatment and physical illness), psychological features and personality patterns [20]. TYPES

OF STUDY

FOUND

IN THE LITERATURE

The numerous quantitative research reports [21] which have been concerned with the association between unemployment and ‘the suicidal tendency’ can be differentiated into four major types. Following Dooley and Catalan0 [22], we distinguish two orthogonal dimensions: (a) individual vs aggregate measures of unemployment and suicidal behaviour; and (b) cross-sectional vs longitudinal collection of measures. Individual studies measure the relationship between the employment status and suicidal behaviour of individuals, while aggregate studies consider the relationship between the unemployment rate and the (para)suicide rate over time or over geographical areas. The temporal design of the research can either be cross-sectional, measuring the relationship between unemployment and suicide data across individuals or groups at one point in time; or longitudinal, where unemployment in individuals or aggregates is associated with subsequent suicidal behaviour over two or more points in time. The four types of study which result from the intersection of these two dimensions are: individualLcross-sectional (Type I); aggregate-cross-sectional (Type 2); individuallongitudinal (Type 3); aggregate-longitudinal (Type 4). The methodological limitations of each type will be discussed below and substantive findings presented in the next section. Type 1: individual-cross-sectional

studies

The majority of research projects investigating the association between unemployment (or, more generally. employment status) and suicidal behaviour at the individual level have been based on crosssectional surveys of parasuicidesisuicides. Unfortunately, formidable methodological and conceptual problems arise which tend to make comparisons between studies rather doubtful and perhaps invalid. Wide variations can be found in the definition of both unemployment and parasuicide/suicide. In the case of unemployment. it is rarely made clear whether the non-registered jobless are included in the sample and there is a lack of consistency in the classification of

Unemployment

and suicidal behaviour

95

married women who are not in paid employment (i.e. ‘housewife’ vs ‘unemployed’). The definitional problem tends to differ for suicide and parasucide. In research on completed suicide, the major issue concerns variation between nominal and operational definitions within the same study. While each researcher tends to have a fairly clear idea of what s/he means by suicide, in actual fact the data are almost invariably derived from official records (e.g. coroners’ courts) or government statistics which use their own operational criteria to decide what constitutes a suicide. In parasuicide research differences between operational definitions used in the various treatment centres are not uncommon [23]. The major methodological shortcoming of the Type 1 study is that the direction of causality cannot be resolved. While there may be a relationship or association between suicidal behaviour and unemployment, it is not possible, on the basis of a cross-sectional study alone, to claim that unemployment causes suicide or parasuicide. The major alternative model is that the relationship is spurious, the result of self-selection processes. Thus, individuals with a psychiatric illness or ‘personality disorder’ may be more vulnerable to suicidal impulses and also more likely to behave in such a way that increases their risk of being dismissed from, or impulsively quitting, their job (compared to those who are not psychiatrically ill or personality disordered).

A relevant example here is provided in the work of Philip and McCulloch [27]. Two further methodological points concerning ecological (geographical) correlations are made by Bagley et al. [28], among others. The first concerns the size of the areas used for the analysis. Although studies have sometimes based their analysis upon boroughs of over 100,000 people [29] or on city wards of over 10,000 people [27], problems are likely to ensue as a result of the social heterogeneity of such large areas. “In theory the problems of ecological correlations should be decreased if smaller areas are used, since the population of such areas is more homogeneous’ [28]. The second problem is that of ‘spatial autocorrelation’. This refers to the fact that while the units of analysis used in calculating correlation coefficients are presumed to be independent of one another, this situation rarely holds with geographical data: contiguous areas tend to be like one another in social and economic characteristics.

T_+pe2: aggregate-cross-sectional studies In Type 2 and Type 4 (aggregate) studies, unemployment and suicide/parasuicide are treated as emergent macro-social variables rather than as properties or characteristics of individuals. In the crosssectional approach, the investigator calculates rebetween correlations) lationships (ecological unemployment and suicidal behaviour rates across geographical areas (e.g. city wards, countries) at one point in time. This type of correlation can point to the presence and strength of association between unemployment and suicidal behaviour, but neither can be used to make any claims about the direction of causality. Furthermore, the relationship between the variables may be spurious. For instance, the variation in the dependent variable (suicide/parasuicide rate) may be ‘due to’ change in extraneous variables other than the hypothetical causal variable (unemployment rate) [24]. Another major limitation of the ecological approach is that a strong association between two rates cannot be used as evidence of an association at the individual level. Such an erroneous inference would, of course, be an example of the ecological fallacy [25]: even where the suicide and unemployment rates are highly correlated, the suicidal or unemployed populations may consist of the same, overlapping or different individuals. However, sociologists continue to use aggregate data to make inferindividuals, because appropriate ences about individual-level data are often not available; and, under certain conditions, aggregate level data do provide unbiassed estimates of individual-level relationships [26]. Furthermore, it is sometimes possible to investigate empirically whether ecological correlations are accompanied by individual correlations.

Type 3: individual-longitudinal studies

“The practical implication of this problem is that correlation coefficients using ecological data will incoporate two measures in a virtually unquantifiable combination: the covariance of data, and the degree of similarity which contiguous social areas possess. This means that correlation coefficients will be higher than those which measure covariance alone. This also means that the application of significance testing to the correlations obtained is inappropriate” [28].

Dooley and Catalan0 note that “few interpretable studies are available to meet the need . . . for individual-level analysis of the impact of economic change on disorder” [22]. The most powerful tool in individual longitudinal studies, the prospective cohort design, is in fact almost unknown in research where suicidal behaviour constitutes the dependent variable. This omission is not only due to the technical and practical difficulties associated with quasiexperimentation, but also (and perhaps more importantly) because of the rarity of extreme deviant behaviour such as suicide. According to Dooley and Catalano, the retrospective design suffers from the same major shortcoming as the cross-sectional approach, in that it cannot provide unambiguous evidence in favour of either competing explanation of the economic changeaisorder relationship (i.e. selfselection us causal mechanisms). However, this similarity in methodological deficiency between the approaches may be more apparent than real. Dooley and Catalan0 apply the label longitudinal to studies by Sainsbury [29], Breed [30] and Tuckman and Lavell [31], among others, which merely report the percentage of suicides who were unemployed at the time of their death. The temporal design of all three studies is cross-sectional, not longitudinal, or else it becomes impossible to differentiate meaningfully between the two types. The distinction between prospective and retrospective approaches depends on whether or not the supposed effects have occurred at the time of the investigation. The importance of the distinction lies in certain practical issues and not in any conceptual differences or differences in interpretation of findings [32].

WI

STEPHEN PLATT

T,vpe 4: aggregate-longitudinal studies Aggregate-longitudinal studies report the association between unemployment rates and rates [33] of suicidal behaviour in a defined geographical area (city. country) over time (usually measured in calendar years). In early studies it was usual to provide a graph or set of data describing trends in suicide and unemployment without any formal statistical test. However, over the years a number of different analytic strategies have become avai!able for use in assessing more objectively the presence and strength of a relationship over time between two or more aggregate phenomena. Collectively, these methods are usually referred to as concomitant time series (CTS) analysis. (For an introduction to CTS analysis, see [34-361.) The simplest statistical model applied to time series analysis is the ordinary least-squares (OLS) regression model, usually expressed by the Pearson correlation coefficient (r). OLS regression assesses the synchronous linear relationship between two time-series variables. However, this method of CTS analysis does not probe the temporal precedence of the variables under study: it provides no evidence concerning whether the presumed cause precedes the presumed effect. Another major shortcoming is that autocorrelated error (which occurs when the residuals from an OLS regression are not independent) frequently renders OLS inappropriate. Consequently, various more sophisticated multiple regression techniques (mainly based on cross-sectional analysis) have been applied in order to examine the issue of temporal precedence and overcome the problem of autocorrelated error. The most well-known exponent in this area of research is Harvey Brenner. In his work the unemployment rate has been conceptualised as “a general and sensitive indicator of the extent of the recession phase of the business cycle” [37] and suicide is one of the mortality categories chosen to represent causes of death ‘reactive to mental stress’. A number of other authors interested in exploring the aggregate relationship between unemployment and suicide [38, 391 also use multiple regression methodology; and Mark [35] actually illustrates eight different approaches to the statistical analysis of concomitances in time series by means of data on United States suicide and unemployment rates for the years 1900-1975. However, a number of technical, methodological and conceptual criticisms have been levelled at time series analysis in general [8,9,22,40-42] and at Brenner’s work, in particular [6, 7,43--17]. Thus, Dooley and Catalan0 question the appropriateness of econometric prediction methods for hypothesis testing in this field: “Until the questions of the existence, sign. and lag of the economic change-disorder relationship are settled, it may be premature to use techniques designed primarily to measure the magnitude of the relationship for forecasting purposes. Econometric techniques, if continued. would be more interpretable and widely convincing if they entailed theoretical speclficatlon of detrending techniques. anticipated regression models and distributed polynomial patterns” [22].

Kasl [41] is severely critical rationale for the detrending series analyses,

of the failure

to offer

any

adjustments made in time given the likelihood that such adjust-

ments will seriously distort the basic data. He is also sceptical of the manner in which investigators ‘scan’ their data in order to determine the ‘optimal’ lag. Scepticism turns to ridicule when the lag time is extended to minus one year. as in Brenner [48]. Marshall and Hodge [49] also refer to the use in Pierce’s work [50] of ‘negative lead’ correlations and comment: “That a hypothesis involving the effect of econonnc condisuicide could be tested if the dependent variable

tions upon is lagged presents a comprehend year could between I

1 to 3 years behind the independent variable problem of causation. It is clearly difficult to how an event or condition existing in any giLen have an impact on events which occurred and 3 years earlier” (p. 106).

Kasl follows Eyer [9] in believing that “the selection of a proper lag should be neither an a priori arbitrary decision, nor an a posteriori optimising-of-results decision, but should be carried out with reference to relevant data from independent studies” [41]. Gravelle et al. [6] have criticised Brenner’s work on England and Wales [5] on the grounds that the model is incorrectly specified, that it omits relevant variables, that better data could have been used, and that Brenner’s estimates are artefacts arising from his choice of time period. On the crucial question of the ability of the aggregate longitudinal strategy to resolve the competing claims of the social causation or selection hypotheses. Dooley and Catalan0 [22] are doubtful. while Kasl [41] is contemptuously dismissive. Brenner himself stresses that: “One cannot establish causation with these procedures. At most, one can test specific hypotheses which are ideally grounded on sound theoretical considerations and earlier research findings. In these tests, the hypotheses are either supported or unsupported by the statistical evidence. Even when they are supported on the basis of statistically significant relations, they are not proven since the statistical tests only indicate whether or not the findings may result from “chance” factors at specific levels of probability. [T] here is also the issue of possible spuriousness even for the relations found to be statistically significant. Regardless of stringent controls, outside influences may have unobservable effects on the relationships. The possibility remains that we have not taken all relevant factors into account, especially since the state of our knowledge in the fields involved is incomplete. Thus, it is possible that some unknown factor may be influencing both the economic trends and those of the pathological indices” [I 11.

Cook

et al. concur

with Brenner

that

“CTS studies share the classical inferential ambiguities associated with correlational research. Most notably, an obtained relationship between X and Y (whether synchronous or lagged or both) might alternatively be explained in terms of a third variable, Z. which causes both X and Y” [34].

Possible candidates for such third variables which ‘account for’ the obtained relationship between unemployment and suicide include “confidence in the political system” [35] and “some as-yet not clearly identified societal impulse [which may possibly] intluence suicide before it is reflected in the economy”[49]. While these suggestions are insufliciently

Unemployment

specific and concrete to be of great heuristic value, the general methodological point remains valid. Unfortunately, a number of CTS analysts are prone to adopt a vulgar Marxist viewpoint which decrees that all changes in the societal superstructure (including health and social customs) are determined solely by changes in the economic infrastructure. Concomitant changes at both levels are assumed to reflect undirectional causation (from the infrastructure to the superstructure). The dangers of this position are well described by Marshall and Hodge: “It is also unlikely that the economy is the lumbering,

always exogenous deux es machina it is frequently portrayed to be. It is often implicitly assumed that the independent and arbitrary perturbations, trends and cycles of the economy “cause” everything to happen; all social and political life waits for the economy to tell it what to do. It certainly does not require revolutionary insight, however, to suspect that social life influences the “exogenous” economy” [49]. THE RELATIONSHIP BETWEEN SUICIDE AND UNEMPLOYMENT: EMPIRICAL EVIDENCE FROM THE LITERATURE Type 1 studies (individual-cross-sectional)

Two case control studies report significantly more unemployment among psychiatric patient suicides than their matched psychiatric controls. Robin et al. [51] found that 10 out of 42 male psychiatric patient suicides (in Southend, England, during the period 1952-1965) were unemployed at the time of their death, compared to only one psychiatric control. However, among females, there was only one unemployed suicide (out of 50) but five unemployed controls (also out of 50). Roy [52] reports that 60 (67”,/,) out of 90 psychiatric patient suicides (in Toronto, Canada, during the period 1968-1979) were unemployed at the time of their death compared to 44 (490,;) of the psychiatric controls (P < 0.02). The difference was extremely pronounced among the men, Table 1. Uncontrolled

studies reporting

the proportion

with 7276 of suicides unemployed compared to 43’1,,; of the controls. but nonsignificant among the women. Several other studies have noted the extent of unemployment among a sample of suicides; the main findings are summarised in Table 1. Although none provides information on the extent of unemployment among a suitable control group [53] a few do refer to the level of unemployment prevailing among nonsuicides. Thus, Sainsbury [29] contrasts the unemployment rate among the males in his suicide sample (32.5%) with the unemployment rate of 1I. 1’;; for the local male population. Tuckman and Lavell note that: “For those below the age of 65, the incidence of unemployment is considerably greater than that found in the general population of Philadelphia, and even this is an underestimation since no information was available on employment for about 30% of cases” [31]. In Yap’s sample of male and female suicides, 29% were unemployed at the time of death; the comparable figure for males and females in the genera1 population was 13.2% [54]. Four studies compare suicide rates among the unemployed with sucide rates among other groups. Sainsbury [29] reports a suicide rate for the unemployed (73.4 per 100,000) which was over five times that of the local population (14.1 per 100,000). The suicide rate for the unemployed in Yap’s sample was 37.2 per 100,000, higher than that of any of the occupational groups [54]. Cumming et al. [55] analyse suicide rates among women in British Columbia, by marital status, age and employment status for the years 1961 and 1971. The 1961 findings reveal that among 25-44 year olds those who are not in the labour force have an excessive rate of suicide compared to those who are in the labour force. While this difference by employment status holds for all marital categories, it is most pronounced for the widowed and the divorced. However, among women aged 15-24 the employed are at greater risk than the not employed. In the 45-64 age group, the not employed of suicides who were unemployed at time of death

Place

Source

97

and suicidal behaviour

Time oeriod covered

Stearns (1921) [58] Sainsbury (1955) [29]

Massachusetts, U.S.A. London. England

1920-1921 19361938

Tuckman and Lavell (1958) [31]

Philadelphia,

1951-1955

Stengel and Cook (1958) [25] Yap (1958) [54] Breed (1963) [30] Maris (1981) [53]

London. England Hong Kong New Orleans, U.S.A. Illinois, U.S.A.

U.S.A.

1953 1953-1954 1954-1959 1966-1968

N in series* ___ M&F M F WM BM WF M M&F WM

167 203 137 485 59 69 73 190 103 146

(1977) [60]

Pallis CI al. (1982) [134]

Bangalore.

India

Sanborn CI al. (1974) [66] Ovenstone (1972. 1973) [19.59] Kraft and Babiglan (1976) (561

West Sussex and Portsmouth. England New Hampshire. U.S.A. Edinburgh. Scotland Monroe County. New York. U.S.A.

Morris er CT/.(1974) [I351

Philadelphia.

lM = male: F = female: W = white: B = black. t53”, altogether not working. :Percentage of suicides who were unemployed.

U.S.A.

or though employed. not working

1967-1973 1968 1968-1970 1969-1971 1969-1971 1972

69 33 26 25 25 7 29 21 35

F M F M&F

32

919 746 75 15 56 118 61 103 50 63 20

M M M F WM BM WF BF

13t 46: 21 7 23 34 IO 15

120 Sathyavathi

M

“, Unemployed

16 3 12

9x

STEPHEN

have higher rates among the married and single. but the employed have higher rates among the widowed. Overall, the regression analysis shows that the standardised regression coefficient associated with employment status is not significant. By contrast, the 1971 regression analysis points to a clearly beneficial effect of work on the suicide rate. Among married, widowed and divorced of all ages the suicide rate among the not employed is higher than that among the employed. The same finding holds also among the single aged under 45 years, but among those aged over 45 years the suicide rate among the employed is greater. Kraft and Babigian [56] report that the rate of 91.8 suicides per 100,000 among the ‘chronically unemployed’ (not defined) is five times the rate for other groups. In a further study, Iga et al. [57] refer to the fact that “in Tokyo, unemployed males show a significantly higher suicide rate than the employed” (p. 510), but no figures are given. In their discussion of the cross-sectional association between unemployment and suicide a number of authors also comment upon the ‘reasons for’ or ‘causes of’ unemployment in their sample. Thus, Stearns [58] shows that out of 167 suicides “36 were unemployed because they were unable to obtain work, 62 because of sickness or old age and 7 for unknown causes”. Tuckman and Lavell [31] claim that in half of the unemployed cases, poor physical or mental health was given as the main reason for unemployment; in 3% of cases, the reasons were lack of seasonal opportunities for work or poor job performance; and in the remaining cases the reason was unknown. In Breed’s series, 50% were not working full time [30]. The reasons given were as follows: 13 were ‘fired’ (of whom 3 were laid off with others in a work force), 3 quit 1-6 days prior to suicide and 12 quit at least 7 days prior to suicide. Ovenstone states that the ‘principal reason’ for unemployment (or non-work among those technically employed) was psychiatric morbidity: 18 out of the 26 unemployed/not working were rated as suffering from psychiatric illness or personality disorder [59]. Finally, a number of Type I studies attempt to make a retrospective assessment of the extent to Table

2. Aggregate-cross-sectional

studies

Author(s) Samsbury Walbran

(1955)

[29]

2 studies (aggregate-cross-sectional) Table 2 lists nine publications ‘in which crosssectional geographical correlations between suicide and unemployment have been reported. It should be unemployment

(621

1929-1933

Principal

[6l]

1954-1961

and

f 1967)

Maliphant

[I361

“Little No

Areas) 1954-1961

CI (I/. (1980)

[8X]

Bagley Farmer Buglass Buglass

*Nine

cl ul. (1973) ef ul. and e, (I/.

[28]

Dulry

(1978)

C1980)

reference\

ue

[64]

[63]

listed

but

evidence

of

geographic

statistical

statistical

correlations

(r = - 0.14,

two

1960-1962

No

1961-1963

Nonsigniticant

1963-1969

Suwde

correlation

be-

and rates of suicide”

test

test of Walbran for

Overall.

6 of

the

slgnilicant

er crl. data.

Nega-

8 years

(two

nqorw

correlation

being

variables

relatlonship neratwe

correlation

countries) rate

r=0.55(P
(I9 wards) London

1969

1973

No

relatlonship

(33 boroughs) Edinburgh

1968

1974

No

relationshlp

(23 city Edmburgh

wards) 1971-1973

No

relationship

(23 c,ty

wards)

these cover

correlations

boroughs)

BrIghton

( 1977) [ 137)

studies

of correlation

negative

significant).

Areas)

Europe (IX

separate

rates of unemployment

formal

Formal tive

Labour

London (28

Sainrbury

seven*

Nonsignificant

between Wallis

from

Significance

tween

Labour

Principal

Market

results

-0.18)

Pennsylvania (I3

rates:

Year(s)

(29 boroughs) Pennsylvania Market

(1970)

Type

London

(I3 Lester

and

which unemployment can be implicated as a likely ‘cause’ of suicide in individual cases. In view of the inherent methodological limitations of this type of exercise, the results should be taken as possibly useful pointers to underlying causal processes rather than accepted uncritically as substantive findings. Stearns [58] claimed that, despite the fact that over 60”, of his sample of suicides were unemployed. “. in no case could [unemployment] be said to be the sole cause [of suicide] . . .” [N]one of this series show suicide as an immediate reaction to the loss of a job”. Likewise. Yap [54] rates only 7 out of 136 males and 1 out of 82 females under the heading ‘unemployment’ in his analysis of suicide by ‘main precipitating cause’. He notes: “A number of cases under [the heading] ‘insanity’ and ‘somatic illness’ were in fact unemployed. but they were not classified as such because their unemployment was clearly a consequence of their disease. In some of the other categories too the subjects were unemployed, but unemployment was not considered to be the main precipitating cause of their [suicidal behaviour]“. On the other hand. Sainsbury [29] claims that “lack of occupation was a factor” among 57 out of the 78 unemployed in his sample who committed suicide: in 24 cases a primary factor. in 33 cases a secondary factor. However, his analysis does not rule out the possibility that the relationship between suicide and unemployment is spurious rather than causal: 9 of the unemployed were dismissed from their jobs, 23 were out of work due to illness, and seven suffered from “chronic lack of employment due to mental or physical incapacity”. The only study which unequivocally links unemployment with subsequent suicide unfortunately provides no information on reasons for unemployment in the sample. Sathyavathi [60] merely states that 657, of the 171 unemployed suicides took their lives “either due to the sole reason of unemployment or for other reasons in addition to the reason of their unemployment”.

Place

( 1965)

PI ul.

of suicide

PLATT

seven mdependant

analyses

(see text).

and

percent

unemployed

correlated

Unemployment

and suicidal

noted that the study by Lester [61] is a replication and extension of the previous work by Walbran er al. [62] which uses the same data. Likewise the Scottish Office study of Edinburgh during 1971-1973 [63] uses data which are included in the analysis by Buglass and Duffy [64]. Thus, the nine publications cover seven separate independent tests of the association between suicide and unemployment rates over geographical areas. Only one conclusion can be drawn from Table 2: there is no such ecological association between suicide and unemployment rates. The findings of Bagley et al. [28] of a significant positive association have to be set against those of Lester [61] which reveal a significant negative correlation (averaged over 8 years). The other studies report no relationship at all between the two variables. Lester [61] puts forward two possible explanations for the negative crosssectional association between unemployment and suicide: firstly, that in areas of low unemployment, the existence of areas of high unemployment may cause the employed individual to feel threatened with the loss of his job, this threat acting as a precipitant of suicide; and, secondly, that those who are unemployed in areas of high unemployment migrate to areas with low unemployment to look for work. One relevant non-geographical Type 2 study has been carried out by Rushing [65] who looked at the relationship between suicide rates (and SMRs), median income and unemployment rates among men aged 20-64 in 64 occupations in the U.S.A. during 1950. He found that the effects of unemployment are clearly stonger at the lower income levels. For the high group of occupations, the income unemployment-suicide relationship was non-existent; for the low income group, the correlation was highly positive. Rushing concludes that the results “clearly suggest that unemployment increases the tendency to suicide among low income groups, while employment may do so among high income groups”. Type 3 studies (individual-longitudinal) 1 have located eight studies employing a longitudinal design which touch upon the association between unemployment and suicide at the individual level. (Although studies by Ovenstone [19,59] and Sanborn et al. [66] contain some information relating to employment status during the time prior to suicide, they are essentially cross-sectional in design and are included in the section above describing Type 1 studies.) Three retrospective analyses are reported by Humphrey 1671, Olsen and Lajer [68] and Shepherd and Barraclough [69]. Humphrey compared suicide victims (N = 98) homicide offenders (N = 62) and a control group of (non-suicidal, non-homicidal) psychoneurotic controls (N = 76) in respect of their experience of ‘occupational loss’. Occupational loss was measured by allocating points for each permanent loss of job, downward mobility, retirement and being laid off from job for more than 2 months in the past year. 95:; of the total sample with high occupational loss were suicides; only 5% were homicides and none were controls [67]. Olsen and Lajer investigated the association between unemployment and cause of death (‘natural’ or ‘violent’, i.e. ‘suicide’ or ‘accident’) in a retrospective study of bricklayers

behaviour

99

and carpenters/cabinetmakers in Denmark during the years 1971-1975. The bricklayers had significantly more unemployment periods, and a significantly higher suicide rate, than the carpentersicabinetmakers. For both occupations considered together, it was found that there were significantly more unemployment periods in the group of violent deaths compared with natural deaths [68]. In a case control study, Shepherd and Barraclough [69] looked at the work record of 75 suicides (including 40 males) and 150 controls (80 males) matched by age, sex, location and whether ever married. They found that significantly fewer suicides were in paid employment at the time of their death and more were off sick or unemployed. Among the men, IO suicides (25%) were not working although economically active and only 4 controls (5’;/,). Altogether, 9 suicides were unemployed (compared to controls): 2 had been dismissed, I for drinking, the other for chronic fault-finding and dissatisfaction; 7 had given up their jobs voluntarily and were then unable or unwilling to find another. of whom 5 gave up work impulsively and 2 gave up as a result of progressive inability to measure up to the demands of work. There was also evidence that, compared to the controls, the employed suicides had been off sick to a greater extent during the previous year. In the whole group the suicides showed more job instability measured by the number of jobs held in the last 3 years [70]. The remaining individual-longitudinal studies are prospective in design. Theorell ef al. [71] found that unemployment lasting over a month or other change at work during the preceding year was significantly associated with subsequent death and ‘neurosis’ (defined as ‘suicide or neurosis, psychoneurosis, anxiety, neurotic depression or asthenia episodes causing sick leave > 30 days’). In order to help ensure independence of the economic change from the dependent variable, all subjects who had been on sick leave for at least 30 days were excluded. The authors do not state how many of the ‘neurosis’ group (N = 32) or ‘all death’ group (N =42), if any, were in fact suicides. Cobb and Kasl looked at the frequency of suicidal behaviour in their pioneering longitudinal investigation of the health and behavioural effects of job loss among 100 married male blue-collar workers (aged 35-60) in two factories which were about to close down permanently [72]. There were two completed suicides, giving a rate about 30 times the rate expected of blue-collar men of this age group. One man was also known to have threatened suicide and another ‘presumably made an attempt’. The authors conclude by expressing their belief that “there was an excess of suicide during the period around the closing of the plant though the figures are not statistically significant” [73]. Two prospective longitudinal studies examine the extent of occupational problems among suicides compared to a group of matched controls. In a psychiatric cohort study of 3563 persons (the Lundby study), Hagnell and Rorsman found that 23 men and 5 women had committed suicide during the 25 year follow up period. Each of these 28 suicides was matched by age, sex and geographical area with two individuals drawn from the cohort and still alive at

100

STEPHEN

the end of the observation period. The authors claim that half (504;) of the suicidal group experienced “[major] occupational problems which probably can explain, at least partly, why they took their lives”. The comparable figure in the non-suicide group was l8”/ (10 out of 56). The difference between the two groups was statistically significant at the 1% level. Examples of ‘major occupational problems’ (not formally defined) included dismissal, strain due to excessive responsibility, accident at work, embezzlement and occupational discontent [74]. Borg and Stahl followed-up 2184 psychiatric in- and outpatients for l-2 years. The 21 males and 13 females who committed suicide during the period of observation were matched by age, sex, diagnosis and patient status with controls from the original census. In contrast to the findings of the Lundby study, Borg and Stahl discovered more ‘problems at work’ (including unemployment, conflicts with fellow workers, unhappiness at work, high level of stress and bad economy) among the controls (13 out of 34) than among the suicides (4 out of 34). This difference was not, however, statistically significant [75]. The most impressive evidence of a link between suicide and unemployment based on general population data comes from the OPCS Longitudinal Study, a continuous multi-cohort study following random samples of individuals through time. The first report [76] is primarily concerned with relationships between mortality in the 5 years following the 1971 Census and characteristics of individuals at Census. The sample used is based on those people selected from the 1971 Census (England and Wales) and subsequently traced in the NHS Central Register; these 513,073 persons represent 1.05% of the 1971 Census population. The standardised mortality ratio (SMR )---set at 100 for the whole population-of men of working age (15-64 years) who were seeking work was raised by 30’//, whereas for those in work it was 14% less than average. Noting (somewhat surprisingly) that “there are no clear health grounds for expecting this category to record high mortality”, the authors recommend that an explanation of the excess deaths among those seeking work should be sought by “looking at the distribution of these men by social class; also at a tendency that men who are less healthy but nevertheless able to work may be unable to hold down a job for a long period and therefore feature disproportionately in their group; and at the possible adverse effects of unemployment” (~26).

When SMRs are characterised by cause of death, it becomes apparent that factors resulting in excess mortality from accidents and violence (SMR = 222) and from malignant neoplasms (SMR = 142) have contributed the major part of the excess overall mortality. “Unemployment may have contributed to an excess of deaths from suicide and related causes” (P. 27). Type 4 .studies (u~~re~ate-longitudincrl) Table 3 summarises the results of 30 studies [77] which have looked at the temporal association between unemployment (or a related indicator of eco-

PLATT

nomic recession) and suicide. The references are listed in approximate chronological order of the time period covered in the analysis. Seven authors fail to make any statistical test of the data (although it is possible to calculate a correlation coefficient from the information provided by Stearns [SS]). The correlational and multiple regression analyses relating to the United States of America are almost unanimous in finding a positive association between undesirable economic change (e.g. increased unemployment) and suicide [78]. An exception is Pierce [50], who found a positive association between absolute economic change (i.e. change per se) and suicide. However, Marshall and Hodge [49] claim that the results of their own analysis of suicide and employment rates provide no support for Pierce’s findings: there is little evidence. . to support Pierce’s suggestion that the recent history of the United States confirms Durkheim with respect to the importance of change, per se, rather than directional change or the state of the economy as an influence upon suicide” (p. 106). “

.

Two studies actually find no relationship between unemployment and suicide rates [79,80] and Marshall [81], although reporting a significant positive correlation, notes that unemployment’s estimated impact on the suicide rate is not significant when multiple regression analysis is employed. However, these findings do not constitute a convincing refutation of the other evidence: in two analyses [79, 811 only restricted age bands are covered, while Catalan0 et al.3 attempt to examine trends in suicide and unemployment on a monthly basis is likely to lead to considerable instability in the computed rates [80]. The evidence relating to Great Britain is more conflicting. Swinscow [33] found a significant correlation between suicide and unemployment over the period 1923-1947, but his analysis is somewhat unsatisfactory in that it uses actual numbers rather than rates [82]. Ahlburg’s study [83] shows that during the 1920s England and Wales experienced a significantly higher rate of change in suicide (after controlling for the rate of change of unemployment) than most other European countries, U.S.A. and Canada. Brenner [5] states that suicide showed an increase within a year of unemployment increasing in England and Wales over the years 1936-1976 but provides no data. When he repeats the analysis for the years 1954/5-1976, no relationship at all is found between total unemployment rate and suicide rate in England and Wales; and the positive relationship at two years lag only in Scotland is shown to be of doubtful reliability. The only significant association with suicide are the variables “unemployment males 20-40 ratio” (in England and Wales) and “unemployment males 40 + ratio” (in Scotland) [84]. Kreitman and Platt [85] report a significant negative correlation between the male unemployment rate and the total male suicide rate in Great Britain during the years 1955-1980. When the time period was further broken down, the relationship between the two variables demonstrated considerable instability: nonsignificantly positive between 1955 and 1963. significantly negative between 1964 and 1972 and significantly positive between 1973 and 1980. In a

101

Unemployment and suicidal hehaviour previous paper, Kreitman [86] had shown that the carbon monoxide (CO) content of domestic gas fell markedly in Great Britain after 1962, and that during Table 3. Aggregate-longitudinal

the following decade suicide specifically due to CO decreased dramatically. He argued convincingly that there was a direct causal relationship between these

studies of suicide and unemployment (or associated indicator of economic recession): evidence from the literature

Author(s)

Place

Period

Statistical procedure*

Thomas (1927) [I381

England

1853-1913

C

Eyer (1977) [9]

U.S.A.

187&l 975

-

Ogburn and Thomas (1922) 11391

U.S.A. (100 cities)

1900-1920

C

Henry and Short (1954) [140]

USA

1900-1947

C

Cook er al. (1980) [34]

U.S.A

1900-1975

C

Mark (1979) [35]

U.S.A.

1900-1975

C

Hurlburt

U.S.A. (cities of over 100,000 population) Australia

1902-1925

-

1905-1976

-

Stearns (1921) [SS]

Massachusetts, U.S.A.

1908-1918

-

Dublin and Bunzel (1933) [143]

U.S.A. Massachusetts, U.S.A. 10 Eastern States, U.S.A. Detroit, U.S.A.

1911-1931 1910-1931 1910-1931

Pierce (1967) [SO]

U.S.A

1919-1940

C

Vigderhous and Fishman (1980) [38]

U.S.A.

1920-1969

MR

Ahlburg (1983) [83]

Germany, Belgium Netherlands, England and Wales. Switzerland, Austria, U.S.A., Canada, France, Italy

1921/2-1931/2

MR

Swinscow (1951) (331

Great Britain

1923-1947

C

MacMahon

U.S.A

1929-1959

-

(1932) [I411

Windschuttle

(1979) [ 1421

Lendrum (1933) [93]

er a/ (1963) [144]

1912-1930

Findings Index of business conditions negatively correlated with suicide rate Graph of trends in suicide rate by age and unemployment rate. “Suicide typically peakIs] within weeks of the peak of the unemployment rate in the business cycle” _ Negative correlation between cycles of suicide rates and cycles of business conditions Suicide rate of males correlated negatively with fluctuations in business (further correlations given for age-sex, race-sex categories) Suicide employment and rates significantly negatively correlated (zero lag) Suicide and unemployment rates significantly positively correlated (zero

lag) Presents chart suggesting “a degree of causal relationship between business activity and suicide” Graph of male suicide rate and percent of males unemployed. Claims that “the peaks and troughs in the male suicide rate correlate very closely to the level of unemployment” Mean annual percentage of unemployment highly correlated with suicide rate?

C

C

C

Inverse correlation between suicide death rate and index of business prosperity Graph of annual suicide rate and stock market averages. Claims “there is little apparent correlation between the two curves”, but no statistical test is made Percent of labour force unemployed correlated at zero lag and 3 year lag with white male suicide rate, but presence of autocorrelation detected. Public definition of economic situation (index based on common stock prices) and age-standard&d white male suicide rate correlated with one year lag-no evidence of autocorrelation Zero-order correlation between unemployment and suicide rates (M and F) highly significant. Regression analysis shows that unemployment “had a dramatic impact upon suicide rates of. males”, particularly during period 1920-1940 Strong inverse relationship across countries between % change in suicide rates and y0 change in several economic indicators, including unemployment. After controlling for rate of change of unemployment, England and Wales and Italy had a significantly higher rate of change in suicide than all other countries Significant correlation between N of and male suicides N of male unemployed “Suicide rates for males in the 45-54 year age group show a remarkable correlation with total unemployment rates in the same year”. Presents graph but no statistical test [Table 3 continued ouerleaf

102

STEPHEN PLATT Table 3:cow. Period

Statistical procedure*

U.S.A.

1933-1970

MR

U.S.A.

1933-1976

MR

1936-1976

MR

U.S.A.

194&1973

MR

U.S.A.

1947-1967

MR

U.S.A.

1948-1972

MR

U.S.A.

1948-1976

MR

John (1982) [89]

West Germany

1950-1980

MR

Brenner

England Wales

1954-1976

MR

Scotland

1955-1976

MR

Great

1955-1980

C

Author(s)

Place

Stack (1981) [145]

Marshall

and Hedge

Brenner

(1979) [5]

Brenner

(1977)

Hammermesh

England Wales

[I I] and Soss (1974) [39]

Marshall

(1970) [Bl]

Ahlburg

and Schapiro

Kreitman

(1981) [49]

(1984) [I461

(1983) [84]

and Platt (1984) [IOO]

and

and

Britam

Waldron

and Eyer (1975) [79]

U.S.A.

1960-1970

Anttine”

er ul. (1983) [I471

Finland

1960-1979

C

1961-1963 to 1972-1974 1962-1972 (by month)

C

1962-1976

C

Samsbury

Cat&no

CI ul (1980) [X8]

CI crl (1982) 1801

Boor (1980) [87]

Europe (IX countries) Monroe County. NY, U.S.A. West Germany. Sweden, Italy. Japan. U.S.A.. Canada. France. Great Brttatn (England and Wales)

“one; C Pearson ‘Key to statistical procedure used in the study. tAlthough no statistxal test was made I” the original ;~“alysls. enough coellicient.

c

Findings Sigmficant association between unemployment and suicide rates (M and F combined). Less pronounced in postwar than m pre-war period Adjusted whne male suicide rate positwely associated wth unemployment rate. Absolute change per se GOI a sq”ficant mftuence on stucide rate Short-term changes in unemployment as a measure of economic loss are the most important source of influence on annual Ructuatlons in mortality. Suicide shows an increase within a year of unemployment mcreasing (no data provided) Increases I” unemployment are related to higher rates of suicide Significant association between unemployment and suicide eve” durmg relatively mild recessions of postwar period-strongest for older age groups Significant positive correlation between unemployment and suicide rates among white males aged 65-74. However. using unemployment’s estiMR analysis. mated impact on suxide rate. though positive. is not significant Significant “npact of ‘labour market tightness’ (i.e. unemployment rate normalised for the changing age structure of the labour force) on male suicide rates. particularly for males aged 45-64 “The level of unemployment apparently does not influence the suicide rate. .” Suicide rate not associated with overall unemployment rate. but w&cant relationship with 2o-40 year old male unemployment ratio at zero lag A positwe relationship between overall unemployment and suicide rates at 2 year lag only (but relationship show” to be unreliable by Chow test). Significant relatIonship wtth unemployment males 40+ ratio at zero lag Significant wgatiw relationship over whole period between male unemployment rate and total male suicide rate. However. unemployment and suicide by means other than domestic gas found to correlate postrice!\ and sigmficantly. Since 1972. unemployment positice/: and signiticantly correlated with total suzlde rate Doubling of suictde among IS-24 year old males “cannot be attributed to rising unemployment” Significant posiriw correlation between unemployment and wcide rate among males aged 15-29: significant negariw correlation among females aged 50-64: all other correlations positive but nonstgnificdnt NonsIgnificant positive correlation between changes m unemployment and changes in suictde rates No relationship between monrhly unemployment rate (M and F) and total. M or F suicide rntes Significant correlations between suicide and unemployment rates m U.S.A.. Canada. Japan and France. Sigmficant nqariw relatIonship m Great Britain

product-moment correlatlo” coelficlent: MR multiple regression. relevanl data were gwe” to permit the calculatmn of a correlation

103

Unemployment and suicidal behaviour

two phenomena. Overall, the decrease in CO suicide was sufficiently large to lower the total suicide rate after 1962 and accounts for the findings of a negative correlation between unemployment and suicide during the following decade. Unemployment and suicide by means other than domestic gas were found to correlate significantly and positively between 1955 and 1980, including during the years 1964-1972 [85]. A few studies report relevant data concerning other European countries. During the period 1962-1976, Boor [87] found a significant positive relationship between suicide and unemployment rates in the U.S.A., Canada, Japan and France; correlations for Germany, Sweden and Italy, though positive, were not significant; and in Great Britain the correlation was significantly negative. Boor’s findings are largely Sainsbury’s discovery of a replicated by nonsignificant association between changes in unemployment and suicide in Europe over the same period [88] and John’s failure to uncover any temporal association in West Germany during the period 1950-1980 [89]. To my knowledge, only one attempt has been made to examine the impact of unemployment on suicide at different historical periods. Ahlburg and Schapiro [90] contrast the independent effect of the economy on suicides during the Great Depression and the post-Second World War period. The results of this analysis suggest to them that the suicide rate is now about twice as responsive to unemployment as was the case during the great depression. THE RELATIONSHIP BETWEEN PARASUICIDE AND UNEMPLOYMENT: EMPIRICAL EVIDENCE FROM THL LITERATURE

Type 1 studies (individual-cross-sectional)

Table 4 presents the available evidence on the relationship between unemployment and parasuicide Table 4. Proportion

SOWX

of parasuicides

who were unemployed on admission to hospital

Type of sample

Hopkins (1937) [97[

cohort

Batchelor (1954) [ 1481

Sample with diagnosis of ‘psychopathic state’ Cohort

Woodside (I 958) [ IO31 Pate1 er 01. (1972) [I491

Kessel (1965) (121

Retrospective sample obtained from case notes Sample from ‘broken home’ Retrospective sample obtained from case notes Cohort

Whitlock and Schapira (1967) [98]

Cohort

Jacobson

Referrals to Psychiatric Unit (30”,, of total N: representativeness uncertain) Retrospective sample obtained from case notes

Bruhn (1962) [94] Pate1 CI a/. (1972) [I491

and Tribe (1972) [I501

Pate1 c, al. (1972) (1491

from cross-sectional surveys of parasuicide samples. Wherever possible, data are given for males only. (If no separate analysis for males has been made, then data refer to both sexes together.) The exclusion of females arises out of the confusion concerning their correct employment status classification, especially among those who are married. In some studies, all married women or women with children (whether married or not) are automatically rated ‘housewives’. In other studies, these groups of women are rated ‘unemployed’ if they are registered as such or even if they merely express an interest in obtaining paid employment. In general, the bulk of studies on parasuicide and unemployment fail to discriminate between groups of women with differing degrees of involvement in the labour market. Warr and Parry [91] have highlighted the same deficiency in studies which examine the relationship between women’s psychological well-being and paid employment. The denominator used in the calculation of the percentage in the final column is usually the total number of male admissions or persons. Ideally, of course, the denominator should be the total number of economically active only. However, although it is possible to obtain these data for Oxford and Edinburgh, they are simply not available in most studies. The use of a rather infIated N in the denominator means that the percentages quoted are somewhat conservative. To give an indication, the percentages for Oxford (19761981) and Edinburgh (1970-1981) would be increased by about 5% and 2% respectively, if the denominator were restricted to the economically active only. Only in rare circumstances would the use of the restricted denominator make a substantial difference to the figure quoted. The noneconomically active include mainly the retired, but a!so those rated ‘not known’ or ‘not applicable’ (e.g. student or in Armed Forces). Given the youthfulness of the parasuicide population, the percentage of

Place/time period covered Liverpool, 1932-193s Edinburgh. 1950-1952 London 19561957 GbdSgOW’.

N in series [males (M) or both sexes

(MF)l*

:/. of admissions unemployed

SO(M)

52

25w)

60

SXMF)

I5

178(M)

II

1956-1960 Edinburgh. 1961-1962 Glasgow. 1961-1965

35(MF)

43

307(M)

I9

Edinburgh, 1962-1963 Newcastle. 1962-1964 Brighton and Hove. 1963. I967

165(M)

34

94(M)

34

I I l(M)

22

Glasgow. 1966-1970

530(M)

23

[Table 4 conrimed

overleajl

104

STEPHEN PLAT? Table 4. conr.

Source Smith

and Davidson

MRC

Unit.

Plawtime period covered

Type of sample (1971) [IO51

Edinburgh

[151]

Cohort Cohort

Pate1 et al. (1972) [I491

Cohort

Morgan

Non-random sample; representativeness uncertain Representative sample Cohort

er ol. (1975) [IO41

Pallis er 01. (1982) [I341 Bancroft

et al. (1975) 1231

O’Brien,

(1981) [I321

Hawton

[I511

MRC

Unit,

Hawton Lendrum ?ap

Edinburgh

Cohort of young adults (aged 15-30) Cohort

[151]

er al. (1982) [96] (1933) [93]

(1958) [54]

Edwards

and Whitlock

(1968) [95]

Maris (1981) [53] Okasha

and Lotaif

Cohort

Cohort ICI8 year olds Cohort Non-random sample; representativeness uncertain Cohort Cohort

(1979) [92]

*Data are given for males only, wherever both s&es are given. t23% of the economically active. :53”/” of the economically active.

Random possible

sample

(for reasons

Newcastle. 1966-1969 Edinburgh, I970 1971 1972 1973 1974 1975 Glasgow. 1971-1972 Bristol. 1972 Chichester. 1972-1973 Oxford. 1972-1973 London. 1975 Oxford, 1976 1977 1978 I979 I980 1981 1982 Edinburgh, 1976 1977 1978 1979 1980 1981 1982 Oxford. I979 Detroit, USA 1927-1930 Hong Kong, 1953-1954 Bnsbane. 1965-1966 Baltimore. U.S.A.. 1970 Cairo. Egypt, 1975

see text). If no separate

males who are retired is relatively small (67; of admissions in Edinburgh, 7% in Oxford, in 1981). There should be no missing data, but invariably some ‘not knowns’ are registered, especially when mass data are gathered routinely, e.g. in Oxford and Edinburgh. (However, even in these centres the proportion of cases rated ‘not known’ on this variable in 1981 were 0% and under I%, respectively.) The number of cases rated ‘not applicable’ will vary, depending mainly on the admission criteria to the hospital, in particular, the inclusion or exclusion of under 16 year olds. It would appear, however, that most reports in the literature concern parasuicide populations aged 15 or 16 years and over. The only study where the omission of ‘not applicable’ cases makes an appreciable difference to the quoted percentage of unemployed is that of Okasha and Lotaif

analysis

.V in series [males (M) or both sexes (MF)]’

0” of Admissions unemployed

209(M)

47

344(M) 439(M) 445(M) 428(M) 423(M) 430(M) 207(M)

42 52 47 49 44 46 55

IZI(M)

36

146(MF)

9

188(M)

15

193(MF)

48

2:3(M) 252(M) 219(M) 207(M) 205(M) 251(M) 213(M)

26 26 33 29 33 39 47

541(M) 522(M) 465(M) 432(M) 444(M) 571(M) 501(M) 25(MF)

49 53 47 40 47 57 62 28

363(M)

17t

127(MF)

28

197(M)

18

64( M F)

33

?OO(MF)

23:

for males has been made, then data on

[92]. Over half of their sample was not economically active (40”/, were students and 16.5% housewives). Thus while 23% of the total n of male and female parasuicides were unemployed, the figure for economically active parasuicides was 53%. Most of the data in Table 4 come from British sources. As far as possible the studies are listed in chronological order of the time period covered. The few relevant non-British studies are listed at the end. Although Table 4 has been set out in rough chronological order to help indentify trends over time, the differences in the types of sample used in the surveys makes this a rather difficult exercise. The most valid and generalisable results are undoubtedly found in the cohort studies. The first such recent studies with a reasonable sample size (Edinburgh, 196221963; Newcastle, 196221964) show identical

Unemployment and suicidal behaviour percentages (34%) of male parasuicides who were unemployed on admission. Thereafter, the tendency is generally towards a higher percentage, although marked fluctuations are evident (e.g. Edinburgh, 1970-1982). The Newcastle cohort of 1966-1969 showed a rate of 477& which increased to over 50% in Edinburgh and Glasgow in 197 l-l 972. The Oxford figures are consistently and strikingly lower than those of Edinburgh over the years 1976-1982. Both series, however, show marked increases in the percentage of unemployed male parasuicides between 1979 and 1982. Some of the studies listed in Table 4 have drawn attention to the fact that the unemployment rate among parasuicides is far greater than the unemployment rate in the general population. Thus, Lendrum [93] notes that while 22.6% of his cohort of attempted suicides were unemployed, the proportion in the population of which they were a sample was 12.2%. Bruhn [94] contrasts the figure of 43% unemployed in his sample with a figure of 17% among matched controls (psychiatric out-patients with no suicide attempt) and less than 4% for the population of Edinburgh. Edwards and Whitlock [95] found that 18% of their cohort of male parasuicides were unemployed in Brisbane, 1965-1966; the rate among general population males was 1.3% in Australia in the same year. Hawton et al. [96] state that the proportion of 16-18 year old parasuicides who were unemployed (28%) “was far higher than that of 16-18 year olds in the general population in the Oxford area at the mid-point of the study (7.3 per cent) [1979]“. Other authors [97,98] merely draw attention to the fact that unemployment among their sample of parasuicides is higher than expected or higher than the average in the general population, without providing exact information. I have located five published references to parasuicide rates among the unemployed compared to the employed. Yap [54] gives details on a sample (whose representativeness is uncertain) of attempted suicides in Hong Kong, 1953-1954. The unemployed constituted 28% of the sample but only 13% of the population (both sexes, 15 years and over). Although no attempted suicide rate is given for the employed as a group, rates are given for individual occupations. The rate for the unemployed (23.9 per 100,000) is second only to the rate for businessmen (36.5); no other rate is above 16 per 100,000. Kessell et al. [99] showed that in a provincial region of Victoria, Australia, the attempted suicide rate of the unemployed over the years 1971-1972 was 2686 per 100,000 unemployed males (1 in 37), more than nineteen times the average rate of 137 per 100,000 males. The incidence in a metropolitan region of Victoria was 1186 per 100,000 males (1 in 84), more than eleven times the area incidence of 100 per 100,000 males. The rates of attempted suicide among unemployed men and women were very similar. When the employed group was differentiated into different occupational categories, the contrast with the unemployed is even more striking. Thus, the suicide attempt rate per 100,000 males in the provincial region was 21 for professionals/managers: 109 for white-collar workers; 234 for blue-collar workers; and 2686 for the unemployed. In the metropolitan region the respective

105

rates (males only) were 24, 149, 234 and 1186. Bancroft et al. [23] report a rate of 145 per 100,000 working males (Oxford area, 1972-I 973), compared to 361 per 100,000 males ‘seeking work, sick, other’. Kreitman [ 161gives parasuicide rates among males in Edinburgh for the period 1968-1970, by employment status. The rate per 100,000 employed was 92 (1 in 1088); per 100,000 unemployed it was 2444 (1 in 40), giving a ratio of nearly 27 : 1. Elsewhere I have presented data on parasuicide rates by employment status in Edinburgh over the years 1968-1982. This analysis reveals a relative risk of parasuicide among the unemployed (compared to the employed) of about 11: 1 during the period 1976-1982. A steep gradient in the relative risk ratio by duration of unemployment was noted. In 1982, Edinburgh men who had been unemployed less than 6 months ran more than six times the risk of parasuicide than did their employed counterparts. This relative risk rose to over 10: 1 among those unemployed 6-12 months, and to nearly 19: 1 among the long-term unemployed [IOO]. Preliminary results from another British study provide indirect confirmation of a relationship between suicidal behaviour and duration of unemployment. Starting in September 1982, Birt has been recording, amongst other key personal data, the employment status of men aged 25-64 and women aged 25-59 becoming ill or dying on account of certain specified conditions (including poisoning) and resident within a defined geographical area (Stockport, Greater Manchester). Analysis of the first 194 subjects entering the study show a crude incidence rate of 0.39 per 1000 employed compared to 1.07 per 1000 unemployed for less than 1 year and 1.38 per 1000 long-term unemployed. (These differences are significant; the overall rate among all unemployed was 1.18 per 1000 [IOI].) The evidence of the overrepresentation of the unemployed among parasuicides is overwhelming; clearly the relative risk of parasuicide is very much elevated for the unemployed compared to the employed. But is joblessness a significant aetiological factor, and if so, in what way? Cross-sectional surveys of parasuicide populations cannot, as we have seen, provide definitive answers to these questions, but they can give some useful pointers to possible associations between parasuicide and unemployment. For instance, we can examine the extent to which unemployment is given as an immediate cause of parasuicide. A number of studies have examined the events leading up to the parasuicide and Table 5 provides evidence of the frequency with which unemployment or associated socio-economic factors are judged to have been major precipitants. However, before accepting at face value the findings presented in Table 5, a certain number of difficulties should be noted. Firstly, studies differ in the meaning given to ‘unemployment’ and in the range of problems which I have included under the rubric ‘related socioeconomic factors’. Secondly, none of the studies listed presents a clear account of the manner in which the rating is made. Is the parasuicide directly asked about the events which precipitated the overdose? If so, how? Is his reply accepted and recorded, or merely used as a guide by’ the interviewer? If the parasuicide is not asked, how is the information gathered?

106

STEPHEN PLATT

Table 5. Unemployment

(or related so&-economic

Source

factor) as a ‘main precipitant studies

Type of sample*

East (1913) [I521

Cohort

Moore

Non-random sample; representativeness uncertain Cohort

(1937) [IO21

Lendrum

(1933) [93]

Hopkins Robins

(1937) [97]

Cohort

er c/l. (1957) [IO71

Yap (1958) [54]

Woodside

(1958) [IO31

Harrington

Krupinski

Whitlock

Cohort

and Cross (1959) (I IO]

Sclare and Hamilton

(1963) [ 1531

et crl. (1966) [I541

and Schapira

Non-random sample: representativeness uncertain Non-random sample; representativeness uncertain

(1967) [98]

Place:time period covered London. 1907-1910 Boston. U.S.A. 1915-1936 Detroit. U.S.A. 1927-1930 Liverpool, 1932-1935 St Louis. U.S.A. 1952-1953 Hong Kong. 1953-1954

sample

Cohort

Cohort

to parasuicide:

.V in series [Males (M) or both sexes

105(M)

363(M)

50(M) 86(MF)

70(M)

55(M) 48(M)

Glasgow, 1960-1962

180(MF)

Victoria. Australia. I963 Newcastle. 1962-1964

204( M )

94(M)

Smith and Davidson

(1971) [IO51

Cohort

Newcastle, 1966-1969

209(M)

Bagadia

[IOS]

Cohort of economically active males

Bombay, India. 1968

255(M)

Bristol, I972

368(MF)

Auckland. New Zealand. 1971-1972 Belfast. 1972-1975

194(M)

Ed 01. (1976)

Werry and. Pedder (1976) [I551

Non-random sample; representativeness uncertain Cohort

Lyons and Bindal (1977) [I561

Cohort

Morgan

er al. (1975) [IO41

of dllrcrent

Type of e\ent and “,, of sample wth such an event

(MF)lt IOOO(MF)

a comparison

Unemployment

I I”, Financial embarrassment and unemployment 37”, Economic 33”, (m&ding unemployment) Iv,, Unemployment Iz” 0 Trouble at work o”,, Economic 47”,, unemployment) I I”, Unemployment 9” I, Socio-economic stress (occupational difficulties. debts and housing problems) I7”0 Financial/employment problem 90’ Finance, work zr other environmental troubles 16% Worries over money, housing or employment I IS, Occupational difficulty 4% Fmanclal worrxs

(including London. 19561957 Birmingham. 19561958

Cohort

Random

cause’ leading

Unemploymen:“” 8” I, unemployed only) 28”,, Worries about work or unemployment 5” 0 Financial or job worries 12”,,

(among

496(MF)

Work problem ?”

0

Redundancy Bancroft

er crl. (1977)

[ 1061

0” I, Representative vamole

Oxford. I972

130(MF)

Work 7””

admissions to Brixton Prison. *All samples are based on patients admitted to hospital, except East [I521 who describes consecutive tData are given for males only, whever possible. If no separate analysis for males has been made, then data on both sexes are given.

Thirdly, in some studies only one major precipitant per person is recorded whereas in others each individual can rate any number of precipitants. The surprising overall impression generated by Table 5 is of the relative unimportance of unemployment or related socio-economic factors as major precipitants of parasuicide. Although Yap [54], Moore [IO21 and Lendrum [93] report substantial percentages, only Lendrum’s sample is likely to be representative and his figure for unemployment alone as a precipitant (18’J$ is not strikingly high. Only 9 of the 17 studies actually refer to ‘un-

employment’ or ‘redundancy’ at all; the average proportion of parasuicides in these samples citing unemployment/redundancy as a causative agent is about 12’7& What is of particular interest is a comparison between percent of sample unemployed and unemployment as a major precipitant within the same study. Fortunately, a number of studies present such data. Thus in Hopkins’ sample [97], 26 of his 50 males were unemployed but in only six cases was unemployment a precipitating cause; and in none of these was it considered to be a ‘primary cause’. Eight of Woodside’s sample [IO31 were unemployed but in

107

Unemployment and suicidal behaviour

only five cases was unemployment a ‘precipitating stress’. Whitlock and Schapira [98] report that 34% of their sample of males were unemployed but only I 1% registered ‘worries over money, housing or employment’ as a ‘main precipitant cause’ of the suicide attempt. Although 36% of Morgan’s sample [104] were unemployed, only 5% claimed that ‘worries about work or unemployment’ triggered that parasuicidal act. Similar discrepancies are found in the studies by Smith and Davidson [ 1051, Bancroft et al. [106] and Yap [54]. Robins ef al. [107] note that although 41 out of 86 patients admitted to hospital after a suicide attempt had experienced ‘job difficulties’ in the 6 months prior to the suicide attempt (i.e. quitting work, being fired, being demoted, excessive friction with others at work), ‘trouble at work’ was never given by the patient as a main reason for his behaviour. According to Bagadia et al. [log], “unemployment was the cause for attempted suicide in only 27.8% of the unemployed group”. The only exception to this pattern is provided by Lendrum [93], who found that while 63 out of 363 male attempted suicides were unemployed (with a further 76 cases rated ‘not known’ on employment status), 66 mentioned unemployment as a motive for their suicidal behaviour! Otherwise, it would appear that while a significant proportion of parasuicides are unemployed on admission to hospital, only a limited number claim that the state of being unemployed is of significance as an immediate cause or precipitant of their suicidal behaviour. Certainly, unemployment appears to be unimportant as a major precipitant, both absolutely and relative to other precipitants. Virtually all studies reach the conclusion that the most important single type of triggering event in parasuicide is ‘interpersonal conflict’, a broad category which includes marital discord, kin disharmony, broken/unhappy love affair, dispute with parents, infidelity, etc. [98, 104, 109-l 131. The relative importance of interpersonal conflict and socio-economic factors (including unemployment) as precipitants of parasuicide are demonstrated in a number of studies. To take only two examples, 65% of a representative sample of suicide attempters in Oxford experienced an event (usually a quarrel) involving a ‘key person’, whereas only 7% experienced events in the ‘work’ category [106]. Among parasuicide admissions to Bristol Royal Infirmary, 510/Ldescribed a major precipitating factor involving interpersonal conflict, whereas only 5% referred to worries about work or unemployment [104]. Type 2 studies (aggregate-cross-sectional)

Macro-level analysis of the relationship between unemployment and parasuicide has been extremely limited. Buglass and Duffy [64] demonstrate the existence of a significant association between parasuicide and unemployment (men seeking work, women seeking work and unemployment in young people) across twenty-three city wards in Edinburgh, 1968-73. Significant ecological correlations for the same town in 1973 alone are also reported, in this case between parasuicide and men and women (separately) seeking work [63]. In both these studies the correlation was higher for men seeking work than for women seeking work. Bagley ef al. [28] also report a

significant positive correlation between parasuicide rates and percent unemployed across nineteen wards in Brighton, 1966-68. It is noteworthy that the studies in both Edinburgh and Brighton also show high correlations between parasuicide and indicators of poverty (e.g. free school meals, non-payment of electricity bills, clothing grants, no inside W.C., no hot tap); and, in Edinburgh alone, parasuicide is linked to juvenile delinquency (e.g. truancy, children referred to the Reporter). Buglass and Duffy [64] characterise the areas where parasuicide is common, and suicide relatively rare, as “lower class districts with associated problems of unemployment, poverty and juvenile delinquency”. Type 3 studies (individual-longitudinal)

Fruensgaard et al. [114] report on the psychological characteristics of 70 unemployed patients (47 men, 23 women) admitted to a psychiatric emergency department in Odense, Denmark. The main reason for admission in about half the sample was suicidal behaviour. It was, estimated that for 41% of the whole sample unemployment had played an important part in the current psychiatric illness, although for only 11% was it the sole etiological factor. Other potentially causal external factors were also registered in three-quarters of the sample. “It seemed that unemployment was most often one of several stressing facets of a complicated interplay” (p. 143). In the case of suicidal behaviour, the authors claim that “unemployment is a significant external factor. . . . However, this effect of unemployment seems most often to be interrelated with other external factors” (p. 144). No other relevant individual-longitudinal study (where parasuicide is the behavioural outcome measure) is known to the author. Type 4 studies (aggregate-longitudinal)

In view of the absence of any formal analysis of the relationship between parasuicide and unemployment, I have examined the relevant data for Edinburgh [loo]. Table 6 presents a summary of the main findings. It reports the male parasuicide person rate, the male unemployment rate and the percentage of economically active male parasuicides who were unemployed on admission, for the years 1968-1982. The rank ordering for each variable across the years is given in parenthesis. Unemployment rate is correlated significantly with both the parasuicide (person) rate (r,, = 0.88, P < 0.001) and with percent of admissions who were unemployed (rr = 0.75, P < 0.01). When unemployment is lagged one year, both correlations are reduced but still significant (r,?=O.71, P co.01 and r,Y= 0.56, P < 0.05, respectively). DECUSSION

The main findings that emerge from the preceding review of the literature on the relationship between unemployment and suicidal behaviour can be briefly summarised. The cross-sectional individual studies reveal that significantly more (para)suicides are unemployed than would be expected among general population samples. Likewise, (para)suicide rates among the unemployed are always considerably

108

STEPHEN

PLAIN

Table 6. Male unemployment and parasuicide in Edinburgh: 1968-1982

Year 1968 I969 1970 1971 I972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982

Male parasuicide (person) rate (per 1O4J.000)* (rank) 157 172 185 218 223 207 208 201 247 237 219 219 226 269 229

---2.7 (15) (14) (13) (9) (61 (11) (10) (12) (2) (3) (7.5) (7.5) (5)

(1) (4)

Male unemployment rate (“:)t (rank) 3.3 4.5 5.6 5.6 4.6 4.4 5.4 6.7 8.0 7.2 6.8 7.7 10.6 12.8

(15)-44.7 (14) (12) (8.5) (8.5) (11) (13) (10) (7) (31 (5) (6) (4) (2) (1)

“; of economically active male parasuicides who were unemployed on admission (rank) 40.2 43.1 54.2 47.1 46.7 42.3 45.2 45.9 50.3 46.0 41.0 49.2 57.4 63.2

(11) (15) (12) (3) (6) (7) (13) (10) (9) (4) (8) (14) (5) (2) (1)

*Mean rate per 100,000 for hospital&d male parasuicides. Edinburgh residents only, 2 I5 years old. The boundaries of the city of Edinburgh were enlarged in 1974. resulting in an increase of 5.5% in the total population. The detinition of an “Edinburgh resident” was changed accordingly. The Resistrar General’s mid-year estimate of the male population in Edinburgh aged b I5 years was used as the denominator in the calculation of the rate. tMales registered with local employment and career services offices covering the Edinburgh. Portobello and Leith employment exchange areas on censusday (June) as percentage of all male employees in employment and those registered as unemployed in the same area.

higher than among the employed. Increasing duration of unemployment is associated with increasing risk of parasuicide. Type 2 (aggregate-crosssectional) studies provided no evidence of a consistent relationship between unemployment and completed suicide, but a significant geographical association between unemployment and parasuicide rates was found. Results from a!! but one of the individual longitudinal studies point to significantly more unemployment, job instability and occupational problems among suicides compared to nonsuicides. The exception is the investigation by Borg and Stahl [7S] which identified (nonsignificantly) more ‘problems at work’ among controls than among suicides (both samples coming from a psychiatric population). The OPCS longitudinal study [76] also found a high suicide rate among the unemployed in the general population. The aggregate longitudinal (Type 4) analyses point to a significant positive association between unemployment and suicide in the United States of America. The negative relationship in Great Britain in the 1960s has been shown to result from a unique decline in the suicide rate due to the unavailability of the most common method of suicide [85, 861. On the relationship between unemployment and suicide Despite this plethora of. research findings, a definitive choice between the competing self-selection and causal models remains highly problematic. We can confidently state that there is an association between uhemployment and suicide but we cannot specify with the same degree of confidence the nature of this association. My own interpretation of the evidence is that empirical support for a direct causal link at the individual level between unemployment and suicide is weak. Attempts to abandon completely any element of self-selection in the suicideunemployment relationship lack credibility because they fail to take cognizance of one crucial fact: namely, that “although mental illness is not a

sufficient cause of suicide, it is for al! practical purposes in modern Western culture probably a necessary one” [115]. Retrospective studies by Barraclough et al. [116], Robins et al. [ 1171 and Dorpat and Ripley [118] show that over 90% of suicide victims are suffering from a major psychiatric illness (most frequently depression but often alcoholism) at the time of death. In his review of the evidence concerning conditions predisposing to suicide, Miles [1!9] concludes that virtually all the suicides in the United States can be attributed. to the following causes: depressive illness, alcoholism, schizophrenia, neurosis and personality disorder and drug addiction. Even if this conclusion is considered to be valid [120], it does not ipsofacto rule out the possibility that it is the individual’s experience of unemployment which increases his/her vulnerability to psychological distress and psychiatric illness, and therefore the risk of suicidal behaviour. Indeed, recently Banks and Jackson [121] have demonstrated a definite causal link between unemployment in young school-leavers and increased psychiatric symptoms (measured by the twelve-item General Health Questionnaire); they also rule out the likelihood of the reverse causation hypothesis, i.e. that the psychologically disturbed cannot find jobs. However, this finding cannot necessarily be generalised to other older populations, and the data do not allow a reliable estimate to be made of the extent to which unemployment in the sample was associated with serious psychiatric disorder. About 40% of the unemployed were found to score above the threshold point on the GHQ- 12, compared to about 13% of the employed (and up to 20% in other general population surveys) [ 1221.This does not mean that 40”/, of the unemployed were psychiatric cases. It merely indicates that among these individuals there was a moderate probability of being found on detailed assessment to be psychiatrically ill. In fact, most of the psychiatric symptomatology was probably mild and transient; Warr reports that when those previously unemployed find work again there is

Unemployment and suicidal behaviour a highly significant reduction in their mean GHQ score [ 1221. The results of this type of investigation are therefore of doubtful relevance for our understanding of the association between unemployment and suicide. Close scrutiny of Type 1 studies leads to the conclusion that among those who eventually commit suicide the temporal and causal sequence of events is quite different from the sequence sketched in the model above. Rather than unemployment leading to psychiatric illness and thereafter to suicide, there is more evidence in favour of the alternative model: Psychiatric

illness

1

p

Unemployment

Suiiide

As we have seen, detailed analyses of individual case histories by Tuckman and LavelI[31], Ovenstone [59], Yap [54], Stearns [58] and Breed [30], among others, lend strong support to the proposition that unemployment in suicide victims is to a large extent a consequence or reflection of an underlying psychiatric disorder: rather than unemployment being a cause of psychiatric illness and suicide, it is more likely that the risks of both unemployment and suicide are elevated by the presence of a major psychiatric illness (in particular, depression). This conclusion is in line with Shepherd and Barraclough’s speculation that the high prevalence of psychiatric ill-health among their sample of suicides “may also have been implicated in the higher rate of unemployment and greater number of job changes. . . Rather than their [the suicides’] work loss resulting from broad social and economic trends, it is more likely that their psychiatric morbidity interfered with their capacity for work, resulting in work loss with its attendant disadvantages, so that mental illness at once stimulated in them

suicidal thinking and at the same time took away from them an effective protection against suicidal behaviour” [69]. The connection between unemployment and suicide (presented as a dashed line in the scheme above) reminds us of the fact that, while psychiatric illness may be directly implicated in suicidal behaviour, it may also operate via unemployment. In particular, the psychological consequences or correlates of prolonged unemployment would appear to be likely to exacerbate the pre-existing psychiatric condition. The long-term unemployed are not only more vulnerable to, and less protected against, stressful life events and difficulties but also face more of these stressors by virtue of being without work. The effects of the psychiatric condition will be potentiated by the interaction between symptoms, stress and vulnerability. Thus far we have only considered individual-level (Type 1) studies which necessarily ignore the role of the economic climate. How, then, can we incorporate our conclusions about the relationship between suicide and unemployment at the individual level with the abundant evidence of a temporal association between suicide and the macro-economy, in a more complete model of the pathways to suicide? A simplified version of such a model may be roughly

I 09

sketched as follows. Macro-economic conditions. although not directly influencing the suicide rate, may nevertheless constitute an important antecedent variable’ in the causal chain leading to self-harmful behaviour. Consequent upon a deepening economic recession, individuals are subjected to greater levels of psychosocial stress. The experience of severe, undesirable life events and difficulties becomes more widespread leading to an increase in psychological disturbance and acute psychiatric illness in the most vulnerable individuals (some of whom may have previously enjoyed excellent psychological health) [123]. Even if a constant proportion of the psychiatric population becomes suicidal (irrespective of the economic climate), then as the pool of psychiatric cases enlarges the number of suicides (and therefore the suicide rate) will automatically rise [124]. The additional psychiatric disorder ‘provoked’ by the economic recession may indeed be found disproportionately among the unemployed, causing an increase in the relative risk of psychiatric illness and suicide among the unemployed compared to the employed. (It would be a matter of considerable theoretical and practical significance to discover whether the increased suicide risk was associated with recent job loss or with long-term unemployment.) On the other hand, the health effects of the recession may be more pronounced among the currently employed, inasmuch as they become anxious about job security and anticipate some future negative changes in their lifestyle, standard of living, feelings of ‘happiness’, etc. arising out of the instability of the macroeconomy [ 1251. If this were the case, we would expect to find that the relative risk of psychiatric illness and suicide among the unemployed (compared to the employed) would remain stationary or even decrease. due mainly to a rise in psychopathology among the employed. This trend might well be accentuated by the tendency for some workers made newly unemployed or redundant to experience relief rather than distress at their change in employment status. It is commonly assumed that all employment is ‘good’ and all unemployment ‘bad’. But unemployment may be ‘good’ for individuals tiho suffer from ‘bad’ employment, i.e. jobs that are inherently stressful or psychologically demeaning or subject to insecurity of tenure, or involve continual change of work environ- ’ ment or require some degree of pliysical separation and isolation from others [126]. On the relationship between unemployment and parasuicide If the data permitted only the roughest outline of a model describing the pathways between economic climate and suicide, then any attempt to delineate the nature of the relationship between unemployment and parasuicide must be even more tentative. There is only one published study which uses a longitudinal design, and only two independent aggregate crosssectional studies. We therefore have to rely almost exclusively on cross-sectional surveys of parasuicidal populations. On the available evidence, can we resolve thz self-selection vs causal argument? One point of interest is the discrepancy between the over-representation of the unemployed among the parasuicides, on the one hand, and the infrequent

110

STEPHEN PLATT

reference to unemployment as a major precipitating cause of parasuicide, at least by those who have committed the act, on the other. This somewhat paradoxical finding does not in fact rule out unemployment as a significant aetiological factor in parasuicide. It has already been pointed out that the rating of ‘precipitants’ of parasuicide is extremely problematic. In addition, the ‘perceptual set’ of psychiatrists may encourage a selective tendency to disregard social factors as precipitants in the quest to demonstrate ‘what everyone already knows’, i.e. interpersonal strife is the main event leading to parasuicide. There is also the possibility that, just as motives for behaviour tend to be formulated according to their likely acceptability to the person’s relevant audience [ 1271, so ‘causes’ or ‘precipitants’ might also be reported differentially according to their perceived acceptability in the hospital setting. On this latter point, however, it is difficult to see why interpersonal conflict should be considered more desirable as an excuse or justification [ 1281 for parasuicide than (recent) unemployment. On the former pointconcerning psychiatrists’ ‘perceptual set’-the importance of interpersonal conflict as the major precipitant has been demonstrated in so many studies in many different countries, and over at least a quarter of a century, that it appears to be a reliable and valid finding. However, if unemployment is not a triggering or it could be aetiologically precipitating event, significant as a predisposing factor. That is to say, unemployment may be parasuicidogenic, not in the sense of being a ‘provoking agent’, but as an ongoing situation causing vulnerability which will increase the risk of suicidal behaviour when a provoking agent is present. (Unemployment may, of course, also have more than one aspect of causal importance: it may act as a provoking agent in some cases and a vulnerability factor in others [129].) Thus, prolonged unemployment may be a significant predisposing factor in suicidal behaviour because it leads to: an increase in family tensions, arguments and violence; more depression and haplessness; increasing isolation from others; changes in role structure within the family; financial hardship and marital deprivation; loss of self-esteem and self-confidence; and feelings of reduced self-worth; or any combination of these sequelae. A provoking agent (e.g. argument with spouse) would be more likely to lead to parasuicide in the presence of unemployment (and its associated behavioural correlates) than in its absence. This causal model of unemployment as a vulnerability factor, or long-term difficulty, rather than as a crisis event, requires evidence that joblesness among parasuicides is not a recent condition and is of significantly longer duration than would be expected among the unemployed in the general population. The scanty data available on this important issue does indeed show that the long-term unemployed are significantly overrepresented in the parasuicide population [IOO, 104, 1051. However, while this finding supports the vulnerability (causal) model, it is of course also compatible with the possibility that certain individuals are at risk of both long-term unemployment and parasuicide by virtue of certain personal characteristics. Although there is not such a

close association between parasuicide and psychiatric illness as was found for suicide, nevertheless surveys of parasuicides have repeatedly claimed that the majority of hospital-based cases are suffering from one or more of the following: a recognised psychiatric illness (usually depression). a personality disorder. alcoholism or alcohol abuse, or habitual drug misuse [ 1301. Furthermore, comparison between employed and unemployed parasuicides shows that significantly more of the unemployed have a previous history of parasuicide and psychiatric treatment; are classified as personality disordered or alcoholic: report a history of family suicide or parasuicide: have behaved violently towards others in the past 5 years; disclose a previous criminal record and face police proceedings at the time of admission; have a problem in the use of alcohol; and habitually misuse drugs [ 13 I]. These cross-sectional data certainly appear to fit well with the expected pathways of a self-selection model. O’Brien [132], for instance, concludes that the discovery of a relationship between previous overdose. personal disorganisation and unemployment in her sample of young adult parasuicides “suggest[s] that unemployment may be a result of difficulties rather than the main cause. People suffering from emotional instability, and maybe alcohol or drug problems. will have difficulty in maintaining a job. or seeking employment”.

Yet, again, the evidence can be shown to be far from conclusive. For instance, very few parasuicide patients are likely to be suffering from severe psychiatric illnesses [133] and most psychopathology has been shown (by Newson-Smith and Hirsch [130]) to be shortlived. Moreover, the significant differences between employed and unemployed parasuicides could equally well arise because long-term unemployment leads to more interpersonal violence, psychiatric treatment, etc. It would appear, then, that we are far from understanding the nature of the relationship between unemployment and parasuicide. Further progress on model-building is unlikely until we have carried outmore empirical research based on a longitudinal design, at both the aggregate and individual levels. Admittedly, a prospective cohort study of parasuicide is not a practical or feasible proposition, but retrospective data on reasons for unemployment, duration of unemployment and previous job history should be obtained in order to test out the importance of personality variables in both unemployment and parasuicide. A controlled retrospective longitudinal study similar to that conducted by Shepherd and Barraciough [69] on completed suicides is an urgent requirement in this area of research. Acknowledgements-I

received considerable help from a number of individuals in the course of preparing this review. In particular I would like to thank Mr Hugh O’Donnel of the Manpower Services Commission, Edinburgh. Mr Jim Connell of the Department of Physical Planning, Lothian Regional Council and Mr A. Spence of the Department of Employment, who all provided me with data on unemployment. Dr Keith Hawton, Department of Psychiatry. Warneford Hospital, Oxford, generously supplied me with unpublished data on the employment status of attempted suicides admitted in Oxford. The present revised version has benefited considerably from the constructive criticrsm of Dr

Unemployment

and suicidal

Norman Kreitman (Medical Research Council Unit for Epidemiological Studies in Psychiatry, Edinburgh) and Mr Mike Porter (Department of General Practice, University of Edinburgh). Dr David Dooley (Public Policy Research Organization, Program in Social Ecology, University of California, Irvine) kindly brought to my attention a number of relevant references I had originally missed. REFERENCES

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16.

17.

House of Commons Parliamentary Debates (Hansard), 37 (67). 366 (3 March 1983). Falret J. P. De L’hyponchondrie el du Suicide. Paris, 1822. Durkheim E. Suicide, p. 241. Routledge & Kegan Paul, London, 1952 (1897). Brenner M. H. Estimating the social costs of national policy: implications for mental and physical health, and criminal aggression. Joint Economic Committee of Congress Paper No. 5, U.S. Government Printing Office. Washington, DC, 1976. Brenner M. H. Mortality and the national economy: a review. and the experience of England and Wales, 1936-76. Lancer 2, 568-573. 1979. Gravelle H. S. E., Hutchinson G. and Stern J. Mortality and unemployment: a critique of Brenner’s timeseries analysis. Lancer 2, 675-679, 1981. Eyer J. Review of ‘Mental Illness and the Economy’. Inr. J. Hlth Serc. 6, 139-148, 1976. Eyer J. Prosperity as a cause of death. In!. J. Hlth Serc. 7, 125-150, 1977. Eyer J. Does unemployment cause the death rate peak in each business cycle? A multifactor model of death rate change. Int. J. Hlrh Sert>. 7, 625-662, 1977. Lancer (editorial). Does unemployment kill? Lance1 1, 708-709. 1979. Brenner M. H. Health costs and benefits of economic policy. Inr. J. Hlth Sew. 7, 581-623. 1977. The term ‘parasuicide’. coined by Kreitman N., Philip A. E., Creer S. and Bagley C. R. (Parasuicide (letter). Br. J. Psychiar. 115, 746-747, 1969). refers “to a behavioural analogue of suicide but without considering a psychological orientation towards death being in any way essential to the definition”. It replaces the term ‘attempted suicide’ which has been extensively criticised on the grounds that is assumes an intention to die is always present in such behaviour. (see e.g. Kessel N. Self-poisoning. Br. med. J. 2, 1265-1270 and 1336-1340. 1965.) Shneidman E. S. Orientation toward death: a vital aspect of the study of lives. Inr. J. Psvchiat. 2,167-200, 1966. Kessel N. The respectability of self-poisoning and the fashion of survival. J. Psychosomat. Res. 10, 29-36, 1966. Stengel E. and Cook N. G. Attempted Suicide, Its Social Significance and Effects. Chapman & Hall, London, 1958. ’ e.g. Kreitman N. Social and clinical aspects of suicide and arrempted suicide. In A Companion to Psychiatric Studies (Edited by Forrest A.), Vol. 1, pp. 38-63. Churchill Livingstone, Edinburgh, 1973; Birtchnell J. and Alarcon J. The motivation and emotiohal state of 91 cases of attempted suicide. Br. J. med. Psycho/. 44, 45-52, 1971; Bancroft J.. Skrimshire A. and Simkin S. The reasons people give for taking overdoses. Br. J. Psl,chiar. 128. 538-548, 1976; Bancroft J.. Hawton K.. S&kin S.. Kingston B.. Cumming C. and Whitwell D. The reasons people give for taking overdoses: a further Inquiry. Br. J. med. Psychol. 52,353-365, 1979; Stengel E. The complexity of motivations to suicide attempts. J. men/. Sri. 106, 1388-1393, 1960. There are, however, some dissenting views, See e.g. Koller K. M. and Cotgrove R. C. M. Social geography

18

19

20

21. 22.

23.

24.

25.

26.

27.

28.

behaviour

III

and suicidal behaviour in Hobart. Ausr. N.Z. JI Psychiar 10, 237-242, 1976; Lester D. Relation between attempted suicide and completed suicide. Psychol. Rep. 27, 719-722, 1970; Lester D. Why People Kill Themselves: A Summary qf Research Findings on Suicidal Behauiour. Charles C. Thomas, Springfield, IL, 1972. Freeman D. J., Wilson K. Thigpen J. and McGee R. K. Assessing intention to die in self-injury behaviour. In Psychological Assessment of Suicidal Risk (Edited by Neuringer C.), pp. 18-42. Charles C. Thomas, Springfield, IL, 1974. See, for example, Kreitman N. The epidemiology of suicide and parasuicide. Crisis 2, l-l 3, 1981; Ovenstone I. M. K. Spectrum of suicidal behaviours in Edinburgh. Br. J. prev. Sot. Med. 27, 27-35, 1973; Dorpat, T. L. and Ripley H. S. The relationship between attempted suicide and committed suicide. Compr. Psychiat. 8, 74-79, 1967; Wilkins J. Suicidal behaviour. Am. sociot. Reo. 32, 286-298, 1967; Kennedy P., Kreitman N. and Ovenstone I. M. K. The prevalence of suicide and parasuicide (‘attempted suicide’) in Edinburgh. Br. J. Psychiar. 124, 36-41, 1974; Shneidman E. S. and Farberow N. L. (Eds) Statistical comparisons between attempted and committed suicides. In. The Crv for He/n DD. 19-47. McGraw-Hill. New York, 196i;-Weiss 3. ‘G. A. The gamble with death in attempted suicide. Psychiarry 20 17-25, 1957; Gibbs J. P. (Ed.) Suicide. Harper & Row, New York, 1968; Schmid C. and van Arsdol M. D. Completed and attempted suicides: a comparative analysis. Am. social. Rev. 20, 273-283, 1955. For useful summaries of these differences see Kreitman N. op. cit., 1973, 1981; Kreitman N. and Dyer J. A. T. Suicide in relation to parasuicide. Medicine 36, 1827-1830, 1980. Space precludes consideration of anecdotal, literary or qualitative approaches to this topic. Dooley D. and Catalan0 R. Economic change as a cause of behavioural disorder. Psychol. Bull. 87, 450-468, 1980. See, for example, differences between Oxford and Edinburgh discussed in Bancroft, J., Skrimshire A., Reynolds F.. Simkin S. and Smith J. Self-noisonine and self-injury in the Oxford area: epidemiologic2 aspects 1969-73. Br. J. prec. Sot. Med. 29, 170-177, 1975. See Rosenberg M. The Logic of Survey Analysis. Basic Books, New York, 1968; and Susser M. Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology. Oxford University Press, London, 1973, among others, for extended discussions on the methods used to screen causal models for extraneous factors. Goodman L. A. Ecological regressions and behaviour of individuals. Am. social. Rev. 18. 663-664. 1953: Robinson W. S. Ecological correlations and the’behav: iour of individuals. Am. social. Ral. 15, 351-357, 1950; Selvin H. C. Durkheim’s ‘Suicide’ and problems of empirical research. Am. J. Social. 63, 607-619, 1958. Morganstem H. Uses of ecological analysis in epidemiological research. Am. J. publ. Hlrh 72, 1336-1344, 1982; Firebaugh G. A rule for inferring individual-level relationships from aggregate data. Am. social. Rec. 43, 557-572, 1978. Philip A. E. and McCulloch J. W. Use of social indices in psychiatric epidemiology. Br. J. prec. Sot. Med. 20, 122-126. 1966; McCulloch J. W. and Philip A. E. Social variables in attempted suicide. Acta psychiar. stand. 43, 341-346, 1967. Bagley C., Jacobson S. and Palmer C. Social structure and the ecological distribution of mental illness. suicide and delinquency. Psychol. Med. 3, 177-l 87, 1973.

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P. Suicide in London. Chapman & Hall, London, 1955. mobility and suicide among 30.Breed W. Occupational white males. Am. social. Rea. 28, 179-188. 1963. 31. Tuckman J. and Lavell M. Study of suicide in Philadelphia. Publ. Hlrh Rep. 73, 547-553, 1958. B. and Pugh T. F. Epidemiology: Prin32. MacMahon ciples and Methods. Little, Brown, Boston. 1970. the data are presented as raw fre33. Exceptionally, quencies rather than rates (e.g. Swinscow D. Some suicide statistics. Br. med. J. 1. 1417-1422, 1951). 34. Cook T. D., Dintzer L. and Mark M. M. The causal analysis of concomitant time series. Appl. sot. Psychol. Ann. 1, 93-135, 1980. in 35. Mark M. The causal analysis of concomitancies time series. In Quasi-Experimentarion (Edited by Cook T. D. and Campbell D. T.), pp. 321-339. HoughtonMifflin, Chicago, 1979. 36. Box G. E. P. and Jenkins G. M. Time Series Analysis: Forecasting and Control. Hoiden-Day, San Francisco, 1976. the health costs of national 37. Brenner M. H. Estimating economic policy in Scotland, 1950-1980. Paper presented at Conference on Unemployment and Health: The Scottish Perspective, Glasgow, 1981. G. and Fishman G. The impact of un38. Vigderhous employment and familial integration on changing suicide rates in the U.S.A., 1920-1969. Sot. Psvchiur. 13, 239-248, 1978. A. S. and Soss. N. M. An economic 39. Hammermesh theorv of suicide. J. Dolit. Econ. 82, 83-98, 1974. and health in macro-social 40. Sprui; I. P. Unemployment analysis. Sot. Sci. Med. 16, 1903-1917. 1982. and the business cycle. Some 41. Kasl S. V. Mortality questions about research strategies when utilising macro-social and ecological data. Am. J. publ. Hlrh 69, 784-788, 1979. of research on economic 42. Kasl S. V. Strategies instabilitv and health. Psvchol. Med. 12, 637-649, 1982. . and its impact on morbidity 43. Stern J. Unemployment and mortalitv. Centre for Labour Economics, L. S. E. Discussion Paper No. 93, London, 1981. really kill? New Sot. 60, 44. Stern J. Does unemployment 421422, 1982. 45. Pollack E. S. Book Review ‘Mental Illness and the Economy’. Am. J. publ. Hlth 64, 512-513, 1974. 46. Colledge M. Economic cycles and health. Towards a sociological understanding of the impact of the recession on health and illness. Sot. Sci. Med. 16, 1919-1927, 1982. 47. Marshall J. R. and Funch D. P. Mental illness and the economy: a critique and partial replication. J. Hlfh sot. Behac. 20, 282-289, 1979. 48. Brenner M. H. Mental Illness and the Economv. Harvard University Press, Cambridge, MA, 1973. 49. Marshall J. R. and Hodge R. W. Durkheim and Pierce on suicide and economic change. Sot. Sci. Res. 10, 101-I 14, 1981. 50. Pierce A. The economic cycle and the social suicide rate. Am. social. Reu. 32, 457462. 1967. D. 51. Robin A. A., Brooke E. M. and Freeman-Browne L. Some aspects of suicide in psychiatric patients in Southend. Br. J. Psvchht. 114. 739-747, 1968. 52. Roy A. Risk factors-for suicide in psychiatric patients. Archs gen. Psychiar. 39, 1089-1095. 1982. Breed [30] interviewed 206 controls (each 53. Although suicide being matched by sex, race and age with two controls), no information on their employment status is presented in this report: and no comparison with the general population is made. Maris’s sample of national deaths is not matched to his sample of suicides (Maris R. W. Parhwqs to Suicide: A Surcey of Self-

29.e.g. Sainsbury

54. 55.

56.

57. 58. 59.

60. 61. 62.

63.

64.

65. 66.

67.

68.

69.

70.

71

72

73. 74.

Destrucrice Behariors. Johns Hopkins University Press, Baltimore, MD. 1981). Yap P. M. Suicide in Hong Kong. J. men/. Sci. 104. 266-301. 1958. Cumming E.. Lazar C. and Chisholm L. Suicide as an index of role strain among employed and not employed married women in B;itish’Coiombia. Gun. Ret,. Social. Anthrov. 12. 463-469. 1975. Kraft D. P. and Babigian H. M. Suicides by persons with and without psychiatric contacts. .drchs gen. Psychiat. 33, 209-215. 1976. Iga M., Yanamoto J., Noguchi T. and Koshinaga J. Suicide in Japan. Sot. Sci. Med. 12. 507-516. 1978. Stearns A. W. Suicide in Massachusetts. Men!. Hyg. 5. 752-777, 1921. Ovenstone I. M. K. An epidemiological study of suicidal behaviours in Edinburgh. M.D. thesis. Umversity of Edinburgh, 1972. Sathyavathi K. Suicide among unemployed persons in Bangalore. Indian J. sot. Work 37, 385-392. 1977. Lest& D. Suicide and unemployment. A reexamination. Archs enoir Hlth 20. 277-278. 1970. Walbran B., MacMahon B. and Bailey A. E. Suicide and unemployment in Pennsylvania, 1954-6 I. Archs enoir. Hlfh 10, 11-15. 1965. Buglass D., Duffy J. and Kreitman N. A Register of Social and Medical Indices By Local Government Area in Edinburgh and the Lothians (2 parts). Central Research Unit, Scottish Office. Edinburgh. 1980. Buglass D. and Duffy J. C. The ecological pattern of suicide and parasuicide in Edinburgh. Sot. Sci. omat. Med. 37. 106-122. 1975: Kasl S. V. and Cobb S. Some mental health consequences of plant closing and job loss, In Mental Health and the Economy (Edited by Ferman L. A. and Gordus J. P.). pp. 255-299. W. E. Upjohn Institute for Employment Research, Kalamazoo, 1979: Cobb S. and Kasl S. V. Termination: The Consequences of Job Loss. DHEW (NIOSH) Publication No. 77-224, Cincinatti. 1977. Cobs S. and Kasl S. V. Some medical aspects of unemployment. Indusr. Geronf. 8, 8-15. 1972. Hagnell 0. and Rorsman B. Suicide in the Lundby

Unemployment

and suicidal behaviour

Study: a controlled prospective investigation of stressful life events. Neuropsychobiology 6, 319-332, 1980. 75. Borg S. E. and Stahl M. Prediction of suicide: a prospective study of suicides and controls among psychiatric patients. Acta psychiaf. stand. 65, 221-232, 1982. 76. Fox A. .I. and Goldblatt P. 0. Longifudinal Study: Socio-demographic and Morrality 1971-1975. HMSO, London, 1982.

D$erentials,

71. Hagen makes an intriguing

reference to a Russian study by Petrakov which apparently finds an association between the suicide rate and chronic unemployment. 1 have not been able to follow this matter further (Hagen D. Q. The relationship between job loss and physical and mental illness. Hosp. Communif. Psychiat. 34, 438-441,

1983).

78. Schapiro and Ahlburg conclude from their calculations that each percentage point increase in the unemployment rate is associated with about 320 more suicides (U.S.A., 1980). They contrast this figure with Brenner’s estimate of 900 additional suicides during a 6-year period (Schapiro M. 0. and Ahlburg D. A. Suicide: the ultimate cost of unemployment. J. Posf Keynsian Econ. 5, 276280,

1982-1983).

79. Waldron J. and Eyer J. Socioeconomic causes of the recent rise in death rates for IS-24 year olds. Sot. Sci. Med. 9, 383-396, 1975. 80. Catalan0 R. A., Dooley D. and Jackson R. Selecting a time-series strategy. Unpublished manuscript, 1982. 81. Marshall J. R. Changes in aged white male suicide: 1948-1972. J. Geronr. 33, 763-768, 1978. 82. The dangers of using numbers rather than rates is nicely illustrated by Cook ef al. [34] who show that the Pearson correlation between the N of suicides and the N of employed persons in the ‘J.S.A. over the years 190@-1975 was +0.83! Once population growth is ‘controlled for’ by using detrended data, the relationship becomes significantly negative (r = -0.59). 83. Ahlburg D. A. The social costs of the Great Depression: a cross-country study of suicide and economic contraction. Unpublished manuscript, 1983. 84. Brenner M. H. Mortality and economic instability: detailed analyses for Britain and comparative analyses for selected industrialized countries. Inr. J. Hlrh Serc. 13, 563-619, 1983. (See especially, Table 6. p. 579.) “The age-sex-specific unemployment ratio is calculated as the age-sex-specific unemployment rate divided by the total unemployment rate” (p.568) “The 2wO-year-old male unemployment ratio tends to indicate severe recession as well as a particularly heavy burden of unemployment on this age group” (p. 598). 85. Kreitman N. and Platt S. Suicide, unemployment and domestic gas detoxification in Great Britain. J. Epid. Communit. H&h 38, 1-6, 1984. 86. Kreitman N. The coal gas story: U.K. suicide rates, 1960-71. Br. J. prec. Sot. Med. 30, 86-93, 1976. 87. Boor M. Relationships between unemployment rates and suicide rates in eight countries, 1962-1976. PryC/IO/.Rep. 47, 1095-1101, 1980. 88 Sainsbury P., Jenkins J. and Levey A. The social correlates of suicide in Europe. In The Suicide Syndrome (Edited by Farmer R. and Hirsch S.), pp. 38-53. Croom Helm, London, 1980. 89. John J. Economic Instability and Health: Infant Mortality and Suicide Reconsidered. Paper presented to W.H.O. Workshop on Health Policy in Relation to Unemployment in the Community, Leeds (U.K.), December 1982. 90. Ahlburg D. A. and Schapiro M. 0. Suicide and unemployment: some earlier evidence. J. Posr Keynsian Econ. In press. 91. Warr P. and Parry G. Paid employment and women’s

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psychological well-being. Psychol. Bull. 91, 498-516. 1982. 92. Okasha A. and Lotaif F. Attempted suicide. An Egyptian investigation. Acfa psychiaf. stand. 60, 69-75,

1979.

93. Lendrum F. C. A thousand cases of attempted suicide. Am. J. Psychiat. 90, 479-500,

1933.

94. Bruhn J. G. Broken homes among attempted suicides and psychiatric outpatients: A comparative study. J. menr: ki.

108, 7721179,

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95. Edwards J. E. and Whitlock E. A. Suicide and attempted suicide in Brisbane. Med. J. Aus!. 1, 932-938,

1968.

96. Hawton K., O’Grady J., Osbom M. and Cole D. Adolescents who take overdoses: their characteristics. problems and contact with helping agencies. Br. J. Psychiaf. 140, 118-123, 1982. 91. Hopkins F. Attempted suicide: an investigation. J. ment. Sci. 83, 71-94, 1937. 98. Whitlock F. A. and Schapira K. Attempted suicide in Newcastle-upon-Tyne. Br. J. Psychiar. 113, 423434. 1967. 99. Kessell A., Nicholson A., Graves G. and Krupinski J. Suicidal attempts in an outer region of metropolitan Melbourne and in a provincial region of Victoria. Aust. N.Z. JI Psvchiat. 9. 255-261. 1975. 100 Platt S. Unemployment and Parasuicide (“attempted suicide”) in Edinburgh, 1968-1982. Unemploy. Unir Bull. 10, 4-5, 1983.

101. Birt C. A. Unemployment, health and sickness in Stockport. In Study on rhe Infruence of Economic Insrabiliry on Health, Newsletter No. 3. Munich, 1983. 102. Moore M. Cases of attempted suicide in a general hospital: a problem in social and psychological medicine. New Engl. J. Med. 217, 291-303, 1937. 103. Woodside M. Attempted suicide arriving at a general hospital. Br. med. J. 2, 411-414, 1958. 104 Morgan H. G., Bums-Cox C. J., Pocock H. and Pottle S. Deliberate self-harm: clinical and socio-economic characteristics of 368 patients. Br. J. Psvchiaf. 127. 564-574, 1975. 105. Smith J. S. and Davidson

K. Changes in the pattern of admissions for attempted suicides in Newcastleupon-Tyne during the 1960s. Br. med. J. 4, 412415. 1971. 106. Bancroft J., Skrimshire A., Casson J., Harvard-Watts 0. and Reynolds F. People who deliberately poison or injure themselves: their problems and their contacts with helping agencies. Psychol. Med. 7, 289-303, 1977. 107. Robins E., Schmidt E. H. and O’Neal P. Some interrelations of social factors and clinical diagnosis in attempted suicide: a study of 109 patients. Am. J. Psychiat. 114, 221-231, 1957. 108. Bagadia V. N., Ghadalia H. N. and

Shah L. P. and attempted suicide. Indian J. Psychiat. 18, 131-139, 1976. 109. Fieldsend R. and Lowenstein E. Quarrels, separations and infidelity in the two days preceding self-poisoning episodes. Br. J. med. Psychol. 54, 349-352, 1981. 110. Harrington J. A. and Cross K. W. Cases of attempted suicide admitted to a general hospital. Br. med. J. 2, Unemployment

463-467.

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111. Adam K.. Bianchi G.. Hawker F., Naim L., Sanford M. and Starr G. Interpersonal factors in suicide attempts: a pilot study in Christchurch. Aust. N.Z. Jl Psychiat. 12, 59-63,

1978.

112. Paykel E. S., Prusoff B. H. and Myers J. K. Suicide attempts and recent life events: a controlled comparison. Archs gen. Psychiar. 32, 327-333, 1975. 113. Paykel E. S. Recent life events and attempted suicide. In The Suicide S.vndrome (Edited by Farmer R. and Hirsch S.), pp. 105-I 15. Croom Helm, London, 1980. 114. Fruensgaard K., Benjaminsen S., Joensen S. and

114

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123.

STEPHENPLATT Helstrup K. Psychosocial characteristics of a group of unemployed patients consecutively admitted to a psychiatric emergency department. Sot. PsJ~#tiur. 18, 137-144, 1983. Brown J. H. Suicide in Britain. More attempts, fewer deaths, lessons for public policy. Archs gen. Ps.rchiat. 36, I1 19-1124. 1979. Barraclough B., Bunch J.. Nelson B. and Sainsbury P. A hundred cases of suicide: clinical aspects. Br. J. Psychiat. 125, 355-373, 1974. Robins E., Gassner S., Kayes J., Wilkinson R. H. and Murphy G. E. The communication of suicidal intent. A study of 134 consecutive cases of successful (completed) suicide. Am. J. Psychiat. 115, 724-733, 1959. Dorpat T. and Ripley H. S. A study of suicide in the Seattle area. Compr. Psychiat. 1, 349-359, 1960. Miles C. P. Conditions oredisnosine to suicide: a review. J. new. ment. Dis.* 164,‘231-246, 1977. It should be noted that many non-psychiatrists are 10th to accept the validity of this association between suicide and psychiatric illness. According to Maris [53] “most suicides are not psychotic, nor even necessarily irrational”. He goes on to criticise studies which report a prevalence of mental illness among suicides approaching loo”,;: “It is well-known that when investigators are aware in advance of their diagnosis that they are evaluating a suicide, their post facturn diagnosis of mental illness is higher than when the subject is evaluated without prior knowledge of suicide” (p. 207). Baechler contends that since suicide is a positive act (“one logical and universal way.. of resolving a problem”), the “really mentally ill” cannot commit suicide. “Where consciousness is eclipsed, no suicides are to be found”. (Baechler J. Suicides, p. 45. Basil Blackwell, Oxford, 1979.) Banks M. H. and Jackson P. R. Unemployment and risk of minor psychiatric disorder in young people: cross-sectional and longitudinal evidence. Psychol. Med. 12, 789-798, 1982. Warr P. Some studies of psychological well-being and unemployment. MRC/ESRC Social and Applied Psychology Unit, Memo No. 431, Sheffield, 1981. Evidence of an association at the aggregate level between changes in the economy and changes in the incidence of psychiatric illness, though strong [4,47.48], is not conclusive (see, for example, Stokes G. and Cochrane R. The relationship between national levels of unemployment and the rate of admission to mental hospitals in England and Wales, 1950-1976. Sot. Psvchiar In press), Catalan0 R. A., Dooley C. D. and Jackson R. L. Economic predictors of admissions to mental health facilities in a nonmetropolitan community. J. Hlth. sot. Behur. 22, 284-297, 1981; Barling P. and Handal P. Incidence of utilization of public mental health facilities as a function of short term economic decline. Am. J. commanil. Psvchol. 8, 3 l-39, 1980: Dooley C. D.. Catalan0 R. A.. Jackson R. L. and Brownell A. Economic. life, and symptom changes in a nonmetropolitan community. J. Hlfh. sot. Behau. 22, 144-154, 1981). Partial support for the hypothesised link between economic contraction, an increase in undesirable stressors and an increase in the incidence of illness and injury has been reported by Catalan0 R. and Dooley D. The health effects of economic instability: a test of the economic stress hypothesis. J. Hlrh. sot. Behar. In press. Qualitied support is also reported for the provocation explanation. whose central tenet is that economic instability somehow cau.;es disorder in previously healthy people which, in turn, increases their likelihood to seek help. However, the same study found evidence m favour of a rival explanation which axsumcs that economic in-

124

125.

126.

127. 128. 129.

130.

131.

132.

133

134

135

stability can lead to help seekmg without causing disorder in previously healthy people (Dooley D. and Catalan0 R. Why the economy predicts help seeking: a test of competing explanations. Submitted for publication). According to an alternative version of this model the impact of economic conditions upon the health of the population would not be reflected in an increase In the number of persons with psychiatric symptoms. but in an increase in the proporrion of the psychiatric pool suffering from a major disorder. Given the association between such disorders and suicide. the suicide rate would be likely to rise also. For further discussion on the stressful effects of the recession upon the employed as well as the unemployed, see, for example. Brenner [37]. Warr P. Job loss, unemployment and psychological well-being. In Role Transitions (Edited by van de Vilert E. and Allen V.). Plenum Press. New York. 1983; Brodsky C. M. Suicide attributed to work. Suicide Life Threat. Behac. 7, 216229. 1977. See also Karcher C. J. and Linden L. L. Is work conducive to self-destruction? Suicide &ye rhrea/. Belnrc. 12, 151-175, 1982. Mills C. W. Situated actions and vocabularies of motives. Am. social. Rer. 5, 904-913. 1940. Scott M. B. and Lyman S. M. Accounts. Ani. social. Rev 33, 46-62, 1968. I am here following the terminology of Brown G. W. and Harris T. Social Origins of Depression. p. 47. Tavistock, London. 1978. In their study of overdose patients assessed using the Present State Examination. Newson-Smith and Hirsch found that psychiatric symptoms were common during the four weeks preceding the act. 31”,, of patients had a definite psychiatric disorder and a further 29”,, were in the border-line or ‘threshold’ categ,ory. All but one patient in these two groups were diagnosed as suffering from depressive disorders. Urwin and Gibbons found that 307; of their sample of self-poisoners had definite disorders and 42”, were in the borderline group. Most were suffering from depression. A quarter of the men and just over I in 10 of the women were classified as having personality disorders. Only onethird of male parasuicide admissions to the Regional Poisoning Treatment Centre. Edinburgh. in 1980 were not classified as either psychiatrically ill or personality disordered or alcoholic. This proportion rose to just under a half in 1981. About a third of male admissions in both years had received previous inpatient psychiatric care. Just under 1 in 5 males reported habitual drug misuse (unpublished data). (NewsonSmith J. G. and Hirsch S. R. Psychiatric symptoms in self-poisoning patients. PsychoI. Med. 9, 493-500. 1979; Urwin P. and Gibbons J. L. Psychiatric diagnosis in self-poisoning patients. Ps~chol. Med. 9. 501-507, 1979.) Platt S. and Duffy J. Parasuicide and unemployment: an empirical analysis based on a three-year cohort of male parasuicide admissions. Submitted for publication. O’Brien S. E. M. A survey of young adults admitted to hospital for self-poisoning in a Central London District, February 1975-August 1976. Ph.D. Thesis. University of London, 198 I. Morgan et al. [IO31 report that only 12”,, of their sample of 337 parasuicides were diagnosed as suITering from a major functional psychotic illness. Pallis D. J.. Barraclough B. M.. Levey,A. B., Jenkins J. S. and Sainsbury P. Estimating suicide risk among attempted suicides: I The development of new clinical scales. Br. J. Psychiur. 141, 37-44. 1982. Morris J. B., Kovacs M.. Beck A. T. and Wolffe A.

Unemployment

136

137

138 139

140 141 142 143.

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145. 146.

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Notes toward an epidemiology of urban suicide. Compr. Psrchiur. 15, 537-547. 1974. Wallis C. P. and Maliphant R. Delinquent areas in the county of London: ecological factors. Br. J. Criminal. 7, 250-284, 1967. Farmer R. D. T.. Preston T. 0. and O’Brien S. E. M. Suicide mortality in Greater London: Changes during the past 25 years. Br. J. prev. Sot. Med. 31, 171-177, 1977. Thomas D. S. Social Aspects q/ the Business Cycle. Knopf. New York, 1927. Ogburn W. F. and Thomas D. S. The influence of the business cycle on certain social conditions. J. Am. Statist. Ass. 18, 324-340. 1922. Henry A. F. and Short J. F. Suicide and Homicide. Free Press, New York, 1954. Hurlburt W. C. Prosperity, depression and the suicide rate. Am. J. Social. 37, 714-719, 1932. Windschuttle K. Vnemploymenf. Penguin Books, Ringwood, Australia, 1979. Dublin L. I. and Bunzel B. To Be or Not To Be, A St& @Suicide. Harrison Smith & Robert Haas, New York, 1933. MacMahon B., Jonhson S. and Pugh T. F. Relation of suicide rates to social conditions. Publ. Hlrh Rep. 78, 285-293, 1963. Stack S. Divorce and suicide: a time series analysis, 1933-1970. J. Fam. Iss. 2, 77-90, 1981. Ahlburg D. A. and Schapiro M. 0. Socioeconomic

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151. 1.52.

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