Nervous and depressive symptoms in a longitudinal study of youth unemployment—selection or exposure?

Journal of Adolescence 1997, 20, 293–305

Nervous and depressive symptoms in a longitudinal study of youth unemployment—selection or exposure? ¨

ANNE HAMMARSTROM AND URBAN JANLERT One thousand and sixty young people were followed for 5 years from the last term of compulsory school. Unemployment correlated positively with changes in nervous complaints and depressive symptoms, even after controlling for initial psychological health and background factors. There were no pronounced gender differences. Qualitative methods were used to study mediating factors between unemployment and mental health, including lack of self-confidence, self-blame, stress, isolation, lack of control and resignation.  1997 The Association for Professionals in Services for Adolescents

Introduction The psychological consequences of unemployment are probably one of¨its most well studied health effects (Eisenberg and Lazarsfeld, 1938; Ezzy, 1993; Hammarstrom, 1994; Winefield, 1995). It has been shown that there is a consistent relationship between unemployment and minor psychological disorders in studies of young people and adults, from different parts of the world, of both ¨ sexes and with different ethnic backgrounds (Kieselbach, 1988; Warr, 1987; Hammarstrom, 1994). Nevertheless, a number of unanswered questions remain. As Winefield (1995) points out, one of the main issues in unemployment research concerns the direction of causality underlying the correlation between unemployment and psychological ill health. Is this correlation a result of selection or exposure? Is it those who already have bad health who become unemployed (selection) or is it unemployment that causes bad health (exposure)? Or will those with bad health become unemployed which in turn worsens their ill health (both selection and exposure)? The issue of selection or exposure is relevant for all psychosocial consequences of unemployment but has mostly been investigated and discussed in relation to alcohol abuse (Hammer, 1991). However, many of the studies being carried out have used a crosssectional design which does not permit the direction of causation to be studied (Crawford et al., 1987). Forcier (1988) concludes that too little attention has been paid to the precise direction of relationships. Investigators have too frequently assumed, for example, that unemployment leads to alcohol abuse, without considering the reverse possibility. The theories and hypotheses in the field can be regarded as a search for a universal theory, valid for all unemployment research. In post-structural research however, there has been a shift from universal theory to an acceptance of theoretical instability (Harding, 1986) with different kinds of theories valid in different social and cultural contexts. Such a theoretical approach might be a more appropriate way of analysing the question of selection or exposure. ¨ Reprint requests and correspondence should be sent to A. Hammarstrom, Department of Family Medicine, ˙ Umea University, S-901 85 UME, Sweden. 0140-1971/97/030293+13/$25·00/0/ad970086 1997 The Association for Professionals in Services for Adolescents

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Self-reported symptoms are the most common way to recognise health problems among young people as observable disease is rare at this age. There are, however, problems with questionnaires; if the teenager in the pre-employment period already has severe symptoms a further deterioration¨ might be difficult to register in a questionnaire. As shown in different studies (Hammarstrom, 1994) young people with health problems are those who are most likely to become unemployed. Thus questionnaires might underestimate the effects of unemployment. Qualitative methodology would be a way to go beyond this problem, in order to open up the field for deeper analysis and better understanding of associations and mechanisms. Many studies of youth unemployment have used the General Health Questionnaire (GHQ) (Goldberg and Hillier, 1979) in order to measure psychological ill health. This instrument has been translated into 40 different languages and given rise to more than 50 published validity studies (Goldberg and Williams, 1988) and is used in order to shed light on minor psychiatric disorder. As the instrument deals with changes during the last 2 weeks it is most suitable for revealing the effects of short-term unemployment rather than the effects of “permanent impermanence”—a situation characterised by shifting between different labour market training programmes, unemployment and odd jobs. Unemployment research has also raised questions about mediating factors. A frequently investigated factor that could influence the consequences of unemployment is work attitudes. The negative influence of high work involvement was identified by Stafford et al. (1980) who observed that adolescents with an orientation towards work experienced a greater loss of self-confidence during unemployment, although a positive result also might be expected: high work values could be a strong incentive for ¨someone who is unemployed to find a way out of unemployment him/herself (Hammarstrom et al., 1988). In a recent longitudinal study, decreased work ¨values were found to be a consequence of unemployment among young men (Hammarstrom, 1996). Thus, low work values can be both a consequence of youth unemployment and a factor mediating its psychological effects. It has been suggested that an external locus of control orientation in the unemployed person may result in a lack of awareness of possibilities of exerting control and hence regaining employment. Research has shown that unemployed young people are more externally controlled than those in employment (Patton and Noller, 1984). In addition, females are more external than males (Furnham, 1984, 1985; Winefield et al., 1993) and also working class subjects tend to be more external oriented. However, Tiggemann and Winefield (1984) failed to show a moderating role of external locus of control in youth unemployment. Another mediating factor that has been studied is increased isolation and loss of social contacts (Donovan and Oddy, 1982). For example, in a Danish qualitative study of unemployed single¨ mothers, isolation was found to be an important factor leading to depression (Beck-Jorgensen, 1991). Lower self-esteem has also been shown to be associated with unemployment in several studies (Patton and Noller, 1984; Warr et al., 1988; Winefield and Tiggemann, 1994). Furnham (1985) draws the conclusion that the paucity of good studies about mediating factors partly explains the lack of clear replicated findings or theories. Most unemployment research has been based on quantitative methods, and has not always provided a deep understanding of what it means to be unemployed, or shed much light on mediating mechanisms or theoretical models.

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Method Subjects This study was carried out in northern Sweden, where unemployment has been endemic for˙ a long time. All the 1083 pupils in the last year of compulsory school in the town of Lulea were included in the study. The pupils were 16-years-old at the start of the study. The first survey was made shortly before the pupils left school in the spring of 1981. All the pupils were surveyed again after 5 years, when they were 21-years-old. Altogether 1060 (500 females and 560 males) responded on the second occasion giving a response rate of 97·9% (of the original sample). Altogether 493 (244 females and 249 males) had experienced unemployment for at least 1 week. The remaining 567 were either employed, engaged in youth opportunity programmes, or full-time students. Five categories of unemployment were distinguished as defined below (individuals can belong to several categories, thus the first group includes all the other groups): (1) those who had been unemployed for at least 1 week during the 5-year period (ever unemployed; n= 244 females, 249 males); (2) those who had been unemployed during the last 3 years for at least 1 week (unemployed last 3 years; n=84 females, 106 males); (3) those who had been unemployed during the last year for at least 1 week (unemployed last year; n=73 females, 87 males); (4) those who were currently unemployed (unemployed now; n=43 females, 49 males); (5) those who had been unemployed for more than half a year during the whole observation period (long-term unemployed; n=69 females, 71 males). Extensive work was carried out in order to reduce the non-respondent rate to a minimum. The total non-participation rate in the study (including the original nonparticipants in 1981) was 2% including four persons who died during the 5 year period.

Materials Unemployment was continuously followed-up during the period studied through questionnaires, interviews and register checks. The participants completed a comprehensive self-administered questionnaire which was almost identical at the beginning and at the end of the study. It included questions on psychological health as well as information on a number of social background factors and health problems. Two measures of psychological health were used. The first measured nervous complaints and consisted of seven questions about restlessness, lack of concentration, uneasiness, palpitation, anguish and other nervous complaints. The second, a marker for depressive symptoms, consisted of three questions regarding down-heartedness, distress and life dissatisfaction. Every question could be answered on a four-point scale rating the frequency of the phenomenon from never to constantly. The two scales were then constructed by summing answers to the separate questions. The same questions were used at 16 and 21 years of age. Change in scores, mainly the increase in frequency of psychological health problems (nervous complaints and depressive symptoms), was used in order to avoid the selection effect in the analysis as much as possible. This measure was constructed as a dummy variable where 1 stands for a higher frequency of complaints at 21 years of age than at 16, and 0 represents an unchanged or a lowered frequency.

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Procedure The study used both quantitative (mainly questionnaire) and qualitative (mainly interview) methods. The quantitative method was chosen in order to be able to draw conclusions that are valid for a larger population. This method also makes it possible to estimate the size of the effects as well as the connection and interaction between different variables. Thus it is easier to judge questions about selection or exposure. All data were analysed using a standard statistical package for microcomputers (SPSS/PC+). Adjustment for confounding factors (low social group, no secondary school, family members unemployed, low work involvement and loneliness) was made with the logistic regression technique. Thematically structured, taped interviews were carried out at the last follow-up study with those who had been long-term unemployed during the 5-year period. The themes of the interviews were mostly directed towards health and health behaviour, as well as mediating factors. Thus, 72 young women and 97 young men were interviewed for between 10 minutes and one and a half hours, depending mainly on the length of unemployment and what the interviewee wanted to tell. No one refused to participate. The interviews were transcribed, after which they were coded and categorised into different themes. Quotations from the interviews were used to illustrate the different themes and the themes were related to some different fragments of theory available within the field of unemployment research (see Discussion section). The qualitative method was chosen in order to explore still not fully understood phenomena, to search for deeper mechanisms and mediating factors, and to try to suggest explanatory theories, which are rare within the field of unemployment health research. It also addressed the following research questions: what it means to be unemployed, and what strategies unemployed young men and women use to escape from unemployment.

Results Questionnaire The total frequency of complaints did not change very much during the observation period. Nervous complaints showed a decrease for women and an increase for men and depressive symptoms a minor decrease for both sexes. While nervous complaints scored higher for women than for men, there were no sex differences regarding depressive symptoms. The first analysis looked at selection from early psychological health to future unemployment. The cohort was dichotomised (median split) into groups with lower and higher frequency of nervous complaints and depressive symptoms at the age of 16 at compulsory school. The groups with low frequencies were used as the reference group, with the odds ratio set at 1. If we compare the probability of becoming unemployed during the observation period with psychological health at the beginning of the study we find that the risk of ever becoming unemployed during the 5-year period, or the risk of becoming long-term unemployed during the same period was significantly raised in certain cases (Table 1). Among men, depressive symptoms in the last year of compulsory school predicted ever being unemployed and nervous symptoms predicted long-term unemployment. Among women, both measures predicted ever unemployed, and depressive symptoms predicted long-term unemployment.

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The second focus of interest was the exposure effect of unemployment on psychological health. Table 2 shows the odds ratios for increases in nervous complaints and depressive symptoms among the unemployed compared to not unemployed, using different criteria for unemployment. All measures used were dichotomous, i.e. the group fulfilling the criterion was compared with the group not fulfilling it. The “employed” group (i.e. the 567 people referred to earlier who were not unemployed) was used as the reference group (with OR=1). In order to take the psychological health from the last year in the compulsory school into account, the predictor variables used in Table 1 (nervous complaints and depressive symptoms) were used as indicators of confounding effects. Thus, two different figures are presented in Table 2—the unadjusted which just shows the odds ratios for increases in health complaints for different unemployment measures, and the adjusted where the odds ratios were adjusted for psychological health at the age of 16. Nervous complaints were adjusted by means of earlier nervous complaints, and depressive symptoms were adjusted by means of earlier depressive symptoms. For both women and men it is shown that a long period of unemployment produced the highest rise in nervous complaints. For women, being unemployed during the last year gave the highest odds ratio regarding increased depressive symptoms. For men, long-term unemployment also had the highest odds ratio for increases in both nervous and depressive symptoms. In general the adjusted figures were somewhat lower than the unadjusted, reflecting the same selection effect as shown in Table 1. There was however one exception: the odds ratio for nervous complaints among women tended to be slightly higher when adjusted for earlier nervous complaints. When comparing the odds ratio for an increase in nervous complaints or depressive symptoms, the longer the unemployment period the higher the odds ratio for increases in symptoms (Figure 1). Regarding nervous complaints there was a fairly uniform increase with increasing Table 1 Mean odds ratios (OR) and 95% confidence intervals (CI) for becoming unemployed during the observed period for those with more than average psychological health problems in the last year of compulsory schooling Psychological health measure

Ever unemployed Men (n=249) OR

Low in nervous complaints High in nervous complaints Low in depressive symptoms High in depressive symptoms

CI

1

1·36

Women (n=244) OR

CI

1

0·94–1·97

1 1·80*

Long-term unemployed

1·46*

*Significantly greater than 1 (p<0·05).

1·59*

OR

Women (n=69) CI

1

1·02–2·09

1 1·28–2·53

Men (n=71)

1·75*

1·40

CI

1

1·04–2·94

1 1·12–2·27

OR

1·41

0·85–2·35

1 0·85–2·31

2·15* 1·24–3·71

10 500 × (b) 9 8 400 7 6 300 × 5 4 200 × 3 × 2 100 × × 1 × × × × 0 0 0 10 20 30 40 50 60 70 80 90 Weeks unemployed

Number of unemployed

Odds ratio

Odds ratio

10 500 × (a) 9 8 400 7 6 300 × 5 4 200 × 3 × 2 100 × × 1 × × × × 0 0 0 10 20 30 40 50 60 70 80 90 Weeks unemployed

Number of unemployed

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Figure 1. Odds ratios for increase in (a) nervous complaints and (b) depressive symptoms compared to the length of unemployment. (r)=women; (j)=men. The right y-axis represent the number of unemployed persons (×).

unemployment length. For depressive symptoms higher odds ratios appeared first after an unemployment period of 1 year or more. There were no pronounced gender differences, except concerning depressive symptoms in relation to long-term unemployment, where young women showed the highest increase. A number of factors might have influenced the development of nervous complaints. Table 2 Mean odds ratios (OR) and 95% confidence intervals (CI) for increase in nervous complaints and depressive symptoms according to different unemployment measures. Adjusted figures using nervous complaints and depressive symptoms as factors in a logistic regression equation Unemployment measure

Increased nervous complaints

Increased depressive symptoms

Men (n=560)

Men (n=560)

OR Ever employed unadjusted 1·45 adjusted 1·42 Unemployed last 3 years unadjusted 2·09* adjusted 2·04* Unemployed last year unadjusted 2·01* adjusted 1·98* Unemployed now unadjusted 1·90* adjusted 1·85* Long-term unemployed unadjusted 2·41* adjusted 2·31*

Women (n=500)

CI

OR

CI

0·99–2·13 0·96–2·09

1·31 1·32

0·86–2·01 0·86–2·02

1·33–3·29 1·29–3·22

OR

CI

1·84* 1·27–2·66 1·73* 1·19–2·51

1·91* 1·76*

1·33–2·74 1·21–2·55

2·07* 1·24–3·46 2·11* 1·26–3·55

1·95* 1·26–3·02 1·87* 1·20–2·91

1·97* 1·83*

1·23–3·16 1·12–2·99

1·24–3·27 1·21–3·23

2·29* 1·34–3·91 2·31* 1·35–3·95

2·24* 1·40–3·58 2·14* 1·33–3·44

2·23* 2·02*

1·35–3·70 1·20–3·41

1·03–3·52 1·00–3·44

2·54* 1·32–4·88 2·62* 1·36–5·06

1·59 1·54

1·84 1·88

0·98–3·46 0·98–3·62

1·43–4·05 1·37–3·89

2·95* 1·72–5·05 3·00* 1·75–5·15

2·35* 1·42–3·90 2·28* 1·37–3·80

1·98* 1·70*

1·18–3·31 1·00–2·89

*Significantly greater than 1 (p<0·05).

OR

CI

Women (n=500)

0·87–2·92 0·83–2·84

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Table 3 shows that notwithstanding a number of potentially confounding factors (of which only loneliness for depressive symptoms among women had an effect) long-term unemployment still remained the most important factor of those studied in explaining nervous complaints and depressive symptoms. There was a general decrease of the odds ratios for long-term unemployed when adjustment was made for the factors in Table 2. Nonetheless, all but depressive symptoms in women were statistically significant. Important influences for men were lack of secondary schooling and a family history of unemployment. For women the most important factor seemed to be loneliness, although unemployment in the family and no secondary school were also important.

Interviews The interviews revealed complex relationships between unemployment and mental health. Four different kinds of relationships were distinguished in the interviews, and can be summarised as follows.

Unemployment leads to increased health. Some of the unemployed, especially Table 3 Mean odds ratios (OR) and 95% confidence intervals (CI) when adjustment is made for different factors Factor

Nervous complaints Men (n=560) OR

Unadjusted Long-term unemployment Adjusted No long-term unemployment Long-term unemployment High social group Low social group Secondary school No secondary school No unemployment in the family Family members unemployed High work involvement Low work involvement No loneliness Loneliness

CI

Depressive symptoms

Women (n=500) OR

CI

Men (n=560) OR

CI

Women (n=500) OR

CI

1·18–3·31

2·41* 1·43–4·05

2·95* 1·72–5·05

2·35* 1·42–3·90

1·98*

1

1

1

1

1·96* 1·06–3·62 1 0·85 0·56–1·27 1

2·80* 1·49–5·25 1 1·08 0·69–1·69 1

2·20* 1·21–4·00 1 0·66 0·45–0·97 1

1·72 1 1·03 1

0·96–3·09

1·63

1·00

1·11

1·44

0·86–2·42

0·92–2·89

1 1·41

1 0·89–2·23

1 1·01 1 0·86

0·55–1·83

1·20

1 0·74–1·95

1 0·98–1·04 0·57–1·29

*Significantly greater than 1 (p=<0·05).

1·00 1 1·41

0·62–1·97

1·69

1 0·98–1·03

1 0·96–1·04 0·90–2·22

1·00 1 1·26

0·71–1·50

1·13

0·74–1·72

1 0·86–1·84 0·86–1·84

1·01 1 1·68*

0·98–1·04 1·15–2·45

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the young men, experienced increased mental well-being during unemployment. Two different categories could be described. The first are seasonal workers, like seamen and building workers, for whom unemployment functions as a paid vacation. The second category can be described as young men in the rural areas who live for hunting, fishing and snowmobile driving. As unemployed they can do what they most of all dream about, but all of them wanted a job in the future. These categories comprise only a few young men who, while unemployed, can do what they most of all want to do.

Unemployment does not affect health. Young people with shorter periods of unemployment expressed no change in perceived health in relation to being unemployed. This was especially true when the unemployed could fill their spare time with meaningful activities or when unemployment was a part of the career, that is when young people became unemployed after having finished a job or an education, waiting for a good job to turn up and rejecting other jobs. Bad health and/or health habits lead to unemployment. Selection of those with bad health and/or health habits into unemployment is the third type of correlation. It is obvious that people with, for example, severe psychiatric illness or people with alcohol problems will have difficulties getting and/or keeping a job. Unemployment leads to ill-health and deteriorated health habits. The predominant impression of the interviews was that unemployment leads to deteriorated health and health habits, which does not exclude the possibility of selection. What we saw can be described as a deterioration of the health among a group which is already worse off compared to others. Quotations from the interviews were used to illustrate what it means to be unemployed and to search for some factors mediating the connection between unemployment and mental ill health. Many girls described how unemployment affected their mental health. Mary has finished 3 years of upper secondary school. Afterwards she worked in different fields, e.g. as a cleaner, but became unemployed for 3 months in total. Her story is as follows: My self-confidence slowly broke down. The first month of unemployment was not so bad. I actively looked for a job, almost anything available. I had lots of things to do, like cleaning up, decorating and being busy about my home as well as meeting my friends. However, it became more and more discouraging not getting any job. I got the feeling I was not worth anything. I felt totally worthless. I became more and more depressed and passive. Soon I didn’t dare to go out. I felt ugly and got the feeling that people were staring at me. I became irritated, impatient and I also quarrelled with everybody. I had colds and was constipated all the time. I started compensatory eating and gained in weight. But somehow I didn’t lose hope. On my own initiative I started studying and thus I broke the vicious circle.

Mary described the pattern from deteriorated self-confidence via depression to nervous problems. The low self-confidence in combination with the passivity that followed both the unemployment and the depression made her isolated. She also described the close connection between the soul and the body; she gets colds, becomes constipated, gains in weight etc. But the interview also shows that Mary has a strong will and a strategy to get out of the vicious circle. Young men with secondary school education also expressed in interviews that their self-

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confidence deteriorated during unemployment. David has a 3-year upper secondary education in science: My self-confidence is wrecked after being unemployed twice during six weeks. With the kind of education I have I shouldn’t become unemployed. There haven’t even been jobs as a cleaner available. But now I have got my self-confidence back, together with a hope for the future after having attended a higher education course in computing at the university.

Lack of self-confidence was a recurrent theme in the interviews with young unemployed women, especially those without secondary school education, e.g. Elisabeth. Elisabeth experiences a vicious circle where the low degree of self-confidence probably prevents her from getting a job, and all job refusals decrease her self-confidence even more. Elisabeth is aware of this mechanism, which makes her even more desperate. She has no education after compulsory school and at the time of the interview she has been unemployed for 2 years. Some people notice immediately that you don’t seem sufficiently interested and that you are not properly dressed. The only job you can get is as a cleaner. That is quite wrecking. I did not look nice enough to get a job, I didn’t behave well enough, wasn’t well dressed, wasn’t open minded. You didn’t look happy and you weren’t in high spirits. But it’s not easy to be happy when you are unemployed, when you get so many “no” and “we’ll see”.

–Do you blame yourself for being unemployed? Yes, because sometimes you get refusals because you don’t look like they have imagined and then you start thinking: How should you really be in order to get a job nowadays. You should be nice, happy and be easy to talk to. I doubt many times that I am that way. But at the same time I know that if I give up I will never get any job.

Another mediating factor is described in an interview with Anne and Helen who both have secondary school education. Helen cannot fall asleep in the evening because of worries: You worry. You get desperate and although you have tried everything nothing happens. You think: what shall I do? Tomorrow something must happen.

Both Anne and Helen are very active in job-seeking. They answer a lot of situations vacant advertisements all over Sweden, they telephone each day to different employers in the largest cities in the south of Sweden and they have also educated themselves in various labour market strategies. But without success so far. They really experience lack of control over their situation. They desperately want to work but they cannot find any. Erica, with a history of 8 months unemployment describes stress as an illness-promoting factor: My mind gets no rest and very often I get a headache. Unemployment stresses you in another way than when you have much to do.

Long-term unemployed boys without upper secondary school education seem to react differently to unemployment. In interviews they often define health as somatic illness only and do not include all their psychological problems which become visible in their questionnaires. Fred’s mother arranged a job for him immediately after the last year of compulsory school. He worked there for 5 years, until recently when he gave notice because of problems with the employer. Fred has no education after compulsory school and at the time of the interview he has been unemployed for 8 months. The interview illustrates that resignation can be a mediating factor between unemployment and in this case drinking behaviour.

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I’ve become lethargic and I’ve stopped struggling. I live one day at a time and I don’t make plans for the future. But most of all I want to work. Unemployment has not made me sick but I drink more.

Very strong reactions, with thoughts of suicide as well as suicide attempts, are expressed by some unemployed boys without upper secondary school education. To sum up, the mechanisms between unemployment and psychological ill-health described in the interviews are: deteriorated self-confidence, self-blame, isolation, stress, resignation and lack of control over the situation. In the next section material from the interviews will be discussed in relation to different theories within the field of unemployment research.

Discussion Despite the 5-year lag between observations the dropout rate in this study was very low. This is of special importance in a study of unemployment effects, ¨ since underprivileged groups are usually overrepresented among the dropouts (Hammarstrom, 1994). Different unemployment measures were used in order to illuminate different aspects of the unemployment phenomenon. Traditionally long-term unemployment (usually defined as more than half a year of unemployment) has been used as the critical variable. Other measures adopted here gave a fairly consistent picture, although there were differences. Obviously the total unemployment experience (i.e. ever unemployed or not) was less relevant than recent or current unemployment. Regarding depressive symptoms, however, current unemployment seems to be of less importance. An explanation might be that there is a time-lag between unemployment and depression, whereas for nervous symptoms the reaction is more immediate. A dose–response association is often considered to be an indication of a causal relationship (Bradford Hill, 1965). Figure 1 gives some support for this, especially regarding nervous complaints. However, as there were rather few people with very long unemployment periods (right axes in Figure 1) the observation may be unreliable. Table 1 shows a significantly higher risk of becoming unemployed for those with psychological problems at the beginning of the study, especially among women. It is thus quite obvious that there was a selection effect, however not a very strong one. Table 2 compares the employment effect without taking account of initial psychological problems (unadjusted odds ratios) with the unemployment effect when initial psychological problems are controlled for (adjusted odds ratios). Although there were slight changes in the ratios, they did not affect the overall result. The study gives support to the hypothesis that both selection and exposure are important in explaining the association between unemployment and psychological ill health (Winefield, 1995). During a boom, selection from the labour force is probably stronger than during a recession, when unemployment hits more blindly. On the other hand a recession will presumably lead to a stronger selection of people who are trying to enter or re-enter the labour force, due to a surplus of job-seekers. For young people who have had no previous job the most relevant factor is selection during the engagement process. Another aspect of the selection/exposure issue is structural. Between the ages of 16 to 18 no selection into unemployment was evident. An explanation might be that the local communities in Sweden were obliged to arrange youth opportunity programmes for

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everyone. There was still a shortage of programmes, but they were allocated randomly to the teenagers. Between the ages of 18 and 21 the local community no longer had the responsibility and the access to labour market programmes diminished. As a consequence the unemployed had to compete with each other, which resulted in socially biased recruitment to the programmes, leading to a selection effect. Another instance of this theory is exemplified by the Rand research (Polich et al., 1980), which concluded that the association between established alcoholism and parallel social deterioration is probably interactive. This means that abusive drinking may lead to job loss and unemployment, which in turn leads to further abusive drinking. In the multivariate analyses factors were considered which in other studies¨ have been shown to influence the probability of becoming unemployed (Hammarstrom, 1994). Despite this, unemployment remained the most important of the factors studied in explaining the decrease of psychological health in the sample (Table 3). For all groups longterm unemployment had the highest odds ratios, even though the figure was non-significant for increased depressive symptoms in women. Unemployment during the last year was the best predictor of depressive symptoms among women (Table 2). The interviews reveal the stressful situation that unemployed young people may experience, both concerning economic stress and stress for having no control and no real demands. Stress is, according to stress theory, one mediating factor between unemployment and ill health (Kagan and Levi, 1975). Stress theory has been confirmed in earlier studies on unemployment among adults, both men (Cobb and Kasl, 1977) and women (Arnetz et al., 1987). Stress may have different effects upon men and women (Frankenhaeuser, 1978) but the gender differences have not been sufficiently studied (Hall, 1990). The economic deprivation model assumes that unemployment leads to poverty and other forms of disadvantage which we know are associated with poor health. Already at the age of 16 health and health behaviour were unevenly distributed among ¨ the boys and girls in the present cohort because of socio-economic factors (Hammarstrom, 1996). Young boys and girls from the most disfavoured social environments had the highest probability of reporting bad health and risky health behaviour. Because of the gender structure within the school system as well as in society girls are more likely than boys to have experienced lack of appreciation, lack of control and lack of meaningful activities at school (Spender, 1980), resulting in higher risk of passivity, reduced self-confidence and increased mental ill health. Low self-confidence probably increases vulnerability to negative life events, such as unemployment. This might explain why unemployed girls tend to express a lack of selfconfidence. The theories of social network/social support is a rapidly growing field of research where human relations are regarded as fundamental needs, with either direct effects on health or buffer effects, protecting against stressful life events, for example unemployment. The quantitative analysis shows that loneliness has an effect of its own on depressive symptoms of young women. The qualitative analyses visualise the process from deteriorated selfconfidence to isolation and ill health. The question could be raised why there isn’t a similar effect on young men. A further qualitative analysis of relationships has been done, showing that young unemployed women seem to care much more for relationships. Relations to persons close ¨ to them seem to be more important for unemployed young women (Hammarstrom, 1996), which is in accordance with gender specific socialisation processes (Miller, 1976, 1986). There is a need for more qualitative unemployment research in order to identify

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unknown or insufficiently understood features of unemployment that affect health so that variations and structures, processes and mechanisms can be discovered. The distinction between selection and exposure would then probably acquire another and deeper meaning, highlighting what unemployment means for the mental health of different people in different social and cultural settings.

Acknowledgements The study was financed by The Swedish Delegation for Social Research and the National Institute of Public Health.

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