- Email: [email protected]
Suicide attempts and job insecurity: a complex association
Eur Psychintry 1998 ; 13 : 359-64 0 Elsevier, Paris
Original article
Suicide attempts and job insecurity: a complex association F Chastang l*, P Rioux I, I Dupont2, 1Department
of Psychiatry,
2 Emergency Department, (Department of Psychiatry,
(Received
21 August
E Baranger4,
‘Department Psychiatric
1997; final
version
V Kovess3, E Zariflan
of Public Health, Caen Hospital, 50100 Saint-Lo, 18 May
1998; accepted
University France
9 July
Hospital,
14033
I Caen;
1998)
Summary - Objective: Since Durkheim, epidemiological studies have revealed a significant, complex association between unemployment and suicidal behaviour. The aim of this study was to analyse the relationship between parasuicide and job instability, including unemployment, French social measures against unemployment and occasional work. Method: Demographic data, personal and familial characteristics were collected in 541 suicide attempters. Results: Seventy-seven per cent were socially active, with 61.5% in regular employment, and 38.5% in precarious employment. The femaleto-male ratio approached 2 in the securely employed sample, and fell to 1 for those with poor social and professional integration. Depression, parasuicide, and alcohol abuse were more common in the families of repeaters in secure employment. The impact of the familial psychiatric background was no longer significant in the job insecurity group. Fostering in childhood was a risk factor for repeat suicidal behaviour in the group with job insecurity. B 1998 Elsevier, Paris psychiatric
emergency
/ parasuicide
/job
insecurity
/ epidemiology
INTRODUCTION
Since Durkheim’s studies, a great number of research from various industrial countries have shown suicide to be consistently and significantly associated with unemployment although no causal relationship could be demonstrated [ 171. Cross-sectional studies provide evidence of significantly higher unemployment rates among suicide attempters than in the general population [lo, 11, 17, 19, 20, 21, 221, while ecological studies show a significant, positive association between suicide attempts and unemployment rates in given geographic areas [5]. Most of these studies were carried out in male populations [ 171. A few reported similar findings in female samples ie, higher suicide rates, as well as higher psychiatric morbidity, in unemployed, compared with employed women [ 11, 251. The nature of the relationship between unemployment and suicidal behaviours remains unclear. A straightforward causality is unlikely; more complex interrelations including social status and psychiatric history seem to be at play [ 10, 111.
*Correspondence
and reprints:
Centre
Esquirol,
CHU
C&e de Nacre,
A characteristic of our current social environment is the absence of a clear distinction between those in work and those who are unemployed. A number of people who would consider themselves unemployed are excluded from official statistics, having taken up temporary work. The issues of social and professional integration and job insecurity go beyond the scope of registered unemployment; in France a set of social measures have been taken in an attempt to control unemployment, mainly by setting up a minimal social security allowance for all (RMI: Revenu Minimal d’Insertion), and government-supported, fixed-term (usually 6 month), part-time, unskilled employment contracts (CES: Contrat Emploi Solida&C). CES contracts apply to unemployed people with particularly poor job perspectives, while any person over 25 who is unable to work but prepared to take part in a social or training program can claim RMI benefits. These measures have had little effect so far in terms of unemployment and job prospects,
especially
14033 Caen cedex, France.
with
the young
who
are
360
F Chastang
increasingly faced with job insecurity. The psychological impact of such issues must be emphasised. The current social environment prompted us to emphasise the concept of job insecurity, which for the purpose of this study includes registered unemployment as well as welfare measures against unemployment (RMI and CES) or occasional work. Despite an abundant international research into the relationship between unemployment and suicidal behaviour, to our knowledge there has been no reference so far in the national or international literature on the relationships between suicidal behaviour, especially repeated suicide attempts, and precarious employment status. The aim of this study (which is part of an investigation carried out between 6 December 1993 and 5 June 1994 which concentrates on patients referred to the Emergency Department of Caen University Hospital for psychological problems) is to examine, in socially active subjects, the relationships between suicidal behaviour and job instability defined as above, with special emphasis on: - firstly, characterising first attempters and repeaters in terms of social and professional integration (whether the subject’s current employment is insecure or not); - secondly, determining the impact of personal and familial factors on repeated suicide according to the level of professional integration; - thirdly, identifying the nature of the relationship between repeated suicide and poor professional integration.
et aJ
suicide, depressive disorder, alcohol or substance abuse. The personal history focused on previous psychological problems, with particular emphasis on suicide attempts, and previous psychiatric hospitalisation or follow-up. The item “family history of depression” was assessed with the question: “has a member of family ever been depressed, that is to say felt so low he or she hardly ate, was unable to work or carry out his daily activities, for a period of a few weeks to several months?” [ 131. Psychiatric assessment was done by qualified psychiatrists according to DSM-III-R criteria [2] in the period shortly following the attempt.
Statistical analyses In order to fulfil the aim of the study, suicide attempters with poor job integration were compared with suicide attempters in employment, for both groups of first attempters and repeaters. Statistical analysis was done with the aid of SASo software, using chi 2 tests(and Yates’ corrected chi 2 when necessary) on qualitative variablesand variance analysis on quantitative variables. Overall and stepwise logistic regression were carried out to determine the role of each variable. The logistic model included variables of sex, age, family history of psychiatric disorder, losses or separationsbefore
the ageof 12. RESULTS Characteristics of socially active suicide attempters
MATERIALS
AND METHODS
Subjects Among suicide attempters
aged
15 or over (n = 541) who
were examined in the Emergency Department of the University Hospital in Caen (France) between 6 December 1993
and 5 June 1994 and included in the original survey, 416 (77%) could be classified as socially active. All school attenders, students, retired or disabled excluded from the present study.
people
were thus
Data collection Patients were evaluated using a 113 item hetero-questionnaire, adapted from the instrument used by V Kovess [ 13 1 in general population enquiries, which covered the following topics: - firstly, social, demographic and professional data, housing and lifestyle; - secondly, reasons for referral (especially: attempted suicide), origin of referral, need for psychotropic medication on the emergency ward; - thirdly: family history of separation before the age of 12 (divorce or separation of parents, death of a family member, fostering in unrelated family or an institution), fatal suicide, attempted
The study sample (n = 416, mean age = 33.6 +/- 1 years, female: 59.4%, male: 40.6%) markedly differs from the socially active general population aged over 15 in the Caen area: suicide attempters were more often divorced (17% vs 6%, P < 0.001) and more often unemployed (17% vs 13.6%. P = 0.01). Fifty four per cent were repeaters, with an average of three previous attempts (table I). Among the 416 socially active suicide attempters, 61.5% were in regular employment, and 38.5% in precarious employment. The female-to-male ratio approached 2 in the securely employed sample, and fell to 1 for those with poor social and professional integration, both in first attempters and repeaters. Suicide attempters with poor integration tended to be younger than those securely employed (5 1% aged less than 25 years against 23%, P < 0.01); lack of social support and absence of fixed housing were also more common in this group. As to family background, selfattempters
more
often
came
from
broken
homes
(20.9% vs 11.6%, P = 0.01) had been in foster homes or families in early childhood (13.9% vs 5.X%, P = O.OOS),had family histories of depression (44.7%
Suicide Table I. Comparison between and the socially active general
attempts
the socially active suicide attempters population from the Caen area (%).
Suicide attempters (n = 416)
General population (n = 86462)
Females Males
59.4 40.6
53.9 46. I
129 >30
47.1 52.9
36.6 63.4
Marital sfutus Unmarried Married Widowed Divorced
47. I 30.0 5.0 16.9
43.8 46.8 3.8 6.0
sex
5 0.001***
5 o.ooi***
5.4 2.6 34.6 13.0 44.4
6.5 13.0 17.8 15.3 47.4
Employment status Employment rate Unemployment rate
61.5 17.0
55.6 13.6
***:
P 2 0.001;
Table II. Comparison between ters and suicide attempters (SA)
P
5 0.001***
Sociaffpi-ofessional status Professionals, executives, university lecturers Intermediate status Employees Workers Others
361
and job insecurity
10.001***
securely employed with job insecurity
suicide (%).
attemp-
Securely SA with job employed SA insecurity (n = 256) (n = 160)
P
Early losses Divorce of parents Fostering
11.6 5.8
20.9 13.9
0.01* 0.005*+
Psychiatric family history Suicide Parasuicide Depression Alcohol abuse Antisocial behaviour Substance abuse Other psychiatric disorder
9.6 lb.7 31.7 26.5 5.0 1.3 2.5
15.3 24.8 44.7 35.7 6.4 7.0 3.8
0.15 0.05* 0.02” 0.05* 0.82 0.02’ 0.70
Personal Previous Previous Previous Psychiatric
66.3 50.6 34.3 20.1
75.9 64.6 44.3 27.2
0.04* 0.01** 0.04* 0.09
***:
psychiatric history psychiatric problem suicide attempt psych. hospitalisation follow-up
P IO.001;
**: 0.001 < P IO.01;
*: 0.01 < P 50.05.
~o.OOl* Table III. Securely ween first-attempters
employed suicide attempters: and repeaters (96).
comparison
bet-
**: 0.001 < P < 0.01; *: 0.01 < P IO.05. First-attempters (n = 120)
vs 31.7%, P = 0.02), alcoholism (35.7% vs 26.4%, P = 0.05) and suicidal behaviour (24.8% vs 16.7%, P = 0.05). Personal histories included significant levels of psychiatric morbidity, especially with regard to suicide attempts (64.6% vs 50.6%, P = 0.01) and previous psychiatric hospitalisations (44.3% vs 34.3%, P = 0.04) (table II). Comparing first attempters fessional status
and repeaters
by pro-
In the securely employed group First attempters represented 50% of suicide attempters in secure employment; they did not differ from repeaters in terms of female/male ratio (approximately 2) matrimonial status, level of education or type of housing. They were, on the contrary, significantly younger. Early losses were no more frequent among first attempters than repeaters. Depression, on the other hand, was significantly more common in the families of repeaters in secure employment (37.4% vs 25.6%. P = 0.05). So was suicide attempt (23.6% vs 13.7%, P = O.OOS>, alcohol consumption (34.1% vs 18.1%, P = 0.02), and other mental disorders (9.8% vs 2.6%, P = 0.02). Previous psychiatric hospitalisations
Early losses Divorce of parents Fostering Psychiatric family history Suicide Parasuicide Depression Alcohol abuse Antisocial behaviour Other psychiatric disorder Personal psychiatric history Previous psy hospitalisation Psychiatric follow-up
Repeaters (n = 1.23)
P
8.5 5.1
14.6 6.5
0.13 0.85
11.1 13.7 25.6 18.1 4.3 2.6
8.1 23.6 37.4 34.1 5.7 9.8
0.45 0.05* 0.05* 0.02* 0.60 0.02*
8.3 R.3
58.5 30.9
2 0.001***
(58.5% vs 8.3%, P < 0.001) and patients followed-up by a specialist (30.9% vs 8.8%, P < 0.001) were also more frequent among repeaters (table Iii). The logistic regression demonstrated that alcoholism and perceived depression within the family are risk factors for repeat suicide. Suicide attempters in regular employment were twice as likely to be repeaters if a member of the family was considered
362
F Chastang
Table IV. Suicide attempters with job insecurity: ween first attempters and repeaters (%). Firstuttempters (n = 56) Early losses Divorce of parents Fostering Psychiatric Suicide
family
comparison
Repeaters (n = 102)
bet-
P
14.5 9.1
24.5 16.7
0.18 0.19
16.4 21.8 38.2 34.5 1.8 I .8
14.7 26.5 48.0 36.3 8.8 4.9
0.42 0.80 6.48 0.88 0.06 0.58
history
PdmSUiCide
Depression AIcohoI abuse Antisocial behaviour Other psychiatric disorder
et al
of depression, suicide attempt, alcohol abuse, and other mental disorders in close members of families were also more frequent in this group, although not reaching statistical significance. Repeaters were also more often treated for psychological problems (32.3% vs 17.9%, P = 0.05) or hospitalised for psychiatric reasons (56.9% vs 21.4%, P < 0.001) (table IV). Multivariate analyses using logistic regression demonstrated that the risk of repeated suicide attempts was 8 times higher among suicide attempters who had been fostered by non-related family (or an institution) early in life (table V). DISCUSSION Representativeness
Personal psychiatric history Previous psy hospitalisation Psychiatric follow-up ***:
P < 0.001;
21.4 17.9
**: 0.001 < P IO.01;
56.9 32.3
6 0.001*** 0.05*
*: 0.01 < P 5 0.05.
Table V. Comparison between first attempters results of the logistic regression analysis.
and repeaters:
Securely employed suicide attempters Adj OR [Cl: 9.5%]
Job insecurity suicide attempters Adj OR [Cl: 95%]
Early losses Divorce of parents Fostering
1.79 [0.72; 4.411 0.19 [0.04; 0.941
2.19 [0.77; 6.181 8.06 [1.35;48.10]
Psychiarric family history Parasuicide Depression Alcohol abuse Other psychiatric disorder
0.94 2.07 2.48 2.37
0.94 1.55 0.84 1.24
OR: odds ratio; CI: confidence
[0.43; [ 1.10; [1.23; [0.80;
2.04] 3.891 4.991 1.251
(0.39; 2.251 [OH; 3.761 [0.39; 1.831 [0.30; 2.151
interval.
depressed, and 2.5 times as likely if there was a family history of alcoholism (table V). In the group with job insecurity Repeaters represented 65% of suicide attempters in insecure employment. The female/male ratio was found to be 0.86 in first attempters compared to 1 among repeaters. Repeaters and first attempters were comparable in terms of age, matrimonial status (although divorce was more frequent among repeaters), social support and level of education. More repeaters, on the other hand, had no permanent home, were living in hostels or institutions, or were homeless. Family backgrounds are similar in both groups, especially in terms of losses before age 12. Histories
The characteristics of the population studied, although very different from those of the general population of similar age, are consistent with data from other sources: suicide attempters are more often female, more often young adults, commonly unmarried, widowed or divorced, and more often unemployed. Our own investigation, however, was restricted to referred patients. It is known that between 20% and 30% of suicide attempters do not get referred to a hospital [9, 14, 291. Suicide attempters with poor social and professional integration may be more likely to be directed to hospital. This hypothesis can be related to Barling’s [3] findings, which demonstrated a positive relationship between the admission rate (especially readmission rate) to psychiatric services and the unemployment rate, taken as an index of economic decline. T~F level of job integration could therefore be a factor in the medical decision to hospitalise. Males’
greater
vulnerability
Most studies on the relationships between suicide and unemployment have been restricted to men. We deliberately chose to consider both male and female suicide attempters in our study, this based on evidence from various sources that unemployed females, like their male counterparts, are at an increased risk of suicide 111, 26, 301. Our female/male ratio of 2 in the regularly employed group is in agreement with the literature on suicide [4], while females and males were alm&t equally represented in the poorly integrated group. This finding is close to Hawton’s [ 10, 1 I] who observed a significantly higher risk of suicide in men than women, with a greater difference between males and females for short-term unemployment. Men’s greater vulnerability to job insecurity can probably be related to the traditional image of the male as bread-
Suicide
attempts
winner in our society. Men’s stronger emphasis and higher estimation of their work, abrupt changes in family roles and social references resulting from unemployment, or even reluctance to create a family for fear of unemployment could significantly aggravate signs of psychological distress. A growing number of women, however, could be affected by the adverse psychological effects of job precariousness. This was suggested by recent reports on suicide rates in industrial countries in the years 1974-1992, which demonstrated a rise in suicides rates in females aged 25 to 34 years that equals that among men in the same age-group. The current trend in our society is undoubtedly towards a change in women’s social behaviour, becoming similar to men’s [24], particularly in terms of women’s involvement in their work, and social recognition of this. Poor job integration
and suicidal
behaviour
The concept of “job precariousness” as defined in our study covers registered unemployment, French social programs against unemployment, as well as very short term employment (C 6 months) or moonlighting. It appears of great relevance/very practical, reflecting the difficulties that many people, especially young people, have in finding, or finding again, a job. Fifty per cent of our suicide attempters in precarious job situations were less than 25. They had experienced twice as many family separations before the age of 12 as suicide attempters in regular employment. Psychiatric family antecedents in terms of suicidal behaviour, depression and alcoholism, as well as psychiatric personal antecedents, especially previous suicide attempts, were also significantly more frequent; repeaters represented 64% of suicide attempters in precarious job situations and 50% of those in regular employment. There was no difference between men and women, either in the regularly or the precariously employed. Our findings are in agreement with the literature, which provides evidence of an increased psychiatric morbidity, especially previous suicide attempts, in the unemployed, whether male or female, getting proportionally greater as the duration of unemployment increases [lo, 11, 16, 231. In men, the risk of self-harm after a year’s unemployment was found to be two to five times higher than after a month and 12 to 18 times higher than in regularly employed people [ 10, 18, 201. The same trend was observed in women, unemployment being identified as a factor independent from other living conditions, such as solitude [ 11, 251. The increased risk of suicide in long term unemployment is difficult to interpret. It may be unrelated to unemployment itself, but rather reflect the fact that
and job insecurity
363
psychologically more vulnerable people may get more rapidly and definitely excluded from work [ 101. Poor job integration
and repeated suicide attempts
Our findings suggest that factors potentially influencing repeated suicide attempts vary according to the level of professional and social integration. Suicide attempters in regular employment were found to have the following family risk factors for repeated suicide attempt: previous suicide attempts, perceived depression or addictive behaviours. Such risks factors are in close relationship with the level of family stability and identification processes which have been shown to generate suicidal behaviours, particularly repeated attempts [7, 8,251. By contrast, family antecedents do not seem to have any direct influence on repeated attempts among the poorly integrated, while multivariate analyses identify early fostering as a determinant of repeat suicide in this group. Such complex relationships between unemployment and suicidal behaviour could be accounted for by the existence of a vulnerability factor formed during the childhood. In a cohort study of 2,256 men followed from childhood into adulthood, Montgomery et al [ 151 demonstrated that social and psychological difficulties in childhood were predictive of unemployment of varying duration later in life, this though after adjusting for confounding factors. Moreover, family instability, particularly in early childhood, is a common factor in young suiciders [ 1,6]. Fostering by non-related family or an institution in childhood, which in our study was found to be far more frequent in recidivists with poor professional integration, bears witness to separation from parental figures, as well as to early, severe and prolonged family disruption, the consequences of which are manifold. Lower self-esteem, greater adaptive difficulties at various stages in life, lingering identification process involving absent or disappointing parental images all result in greater psychological vulnerability [28, 311, which in turn accounts for a higher psychiatric morbidity as well as more difficult social and professional integration, the two being interrelated. The early origin of the subject’s vulnerability to life events could explain the absence of a dkect or indirect causal link between suicide and unemployment [12, 271. In a study of unemployed suicide attempters, Shapiro [27] found that only 4% viewed unemployment as directly related to their suicidal behaviour, while 14% explicitly identified family factors as the cause. Family upheaval, particularly role changing due to unemployment, as well as resulting social and familial diffrculties, could be experienced as a reminiscence of early family instability in childhood.
F Chastang
364
CONCLUSION In a society where job requirements are becoming more demanding, personal characteristics of individuals are important factors to consider, particularly in the context of the complex relationship between suicidal behaviour and job insecurity; early vulnerability factors seem to contribute to greater, more prolonged, difficulties in social and professional integration, and resulting psychological problems. REFERENCES Adam KS, Bouckoms A, Streiner D. Parental loss and family stability in attempted suicide. Arch Gen Psychiarry 1982 ; 39 : 1082-S American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: APA; 1987 Barling PW, Handal PJ. Incidence of utilization of public mental health facilities as a function of short-term economic decline. Am J Community Psycho1 1980 ; 8 : 3 l-9 Bille-Brahe U, Kerkhof A, De Leo D, Schmidtke A, Crepet P, LKnnqvist J et al. A repetition-prediction study of European parasuicide populations: a summary of the first report from Part II of the WHO/EURO Multicentre Study on Parasuicide in co-operation with the EC Concerted Action on Attempted Suicide. Acta Psychiatr Scand 1997 ; 95 : 81-6 Buglass D. Duffy JC. The ecological patterns of suicide and parasuicide in Edinburgh. Sot Sci 1978 ; 12 : 241-53 De Wilde E, Kienhorst ICWK, Diekstra RFW, Wolters WHG. The relationship between adolescent suicidal behavior and life events in childhood and adolescence. Am J Psychiatry 1992 ; 149 : 45-5 I Diekstra RF%‘. Suicide and suicide attempts in the European Economic Community: an analysis of trends with special emphasis on trends among the young. Suicide Life Threat Behav 1985 ; 15 : 402-21 Diekstra RFW. The epidemiology of suicide and parasuicide. Acta Psychiatr Stand 1993 ; suppl37 1 : 9-20 Diekstra RFW, Van Egmond J. Suicide and attempted suicide in general practice 1979-1986. Acta Psychiatr Scand 1989 ; 79 : 268-75
IO Hawton K, Rose N. Factors associated with suicide and parasuitide among men in Oxford. Health Trends 1986 ; I8 : 29-32 I I Hawton K, Fagg 3, Simkin S. Female unemployment and attempted suicide. Brit J Psychiatry 1988 ; I52 : 632-7 I2 Jones SC. Forster DP, Hassanyeh F. The role of unemployment in parasuicide. Psych& Med 1991 ; 21 : 169-76 I.7 Kovess V, Gysens S, Chanoit PF. Une enqu&te de santC
et al mentale : l’enqu&te santC des franciliens. Ann Med Psycho1 1993 ; 151 : 624-7 X, Pueyo S, Toulouse C, Tilly B, Dabis F I4 Maurice S, Pommereau et al. Epidemiological surveillance of suicides and attempted suicides in Aquitaine, south-west France, using an original computer network of sentinel general practitioners. J Epidemiol Community Health 1989 ; 43 : 290-2 15 Montgomery SM, Bartley MJ, Cook DG, Wadsworth MEJ. Health and social precursors of unemployment in young men in Great Britain. J Epidemiol Community Health 1996 ; 50 : 415-22 16 Morton MJ. The prediction of repetition of parasuicide: with special references to unemployment. Int J Sot Psychiatry 1993 ; 39:87-99
Plan S. Unemployment and suicidal behavior: a review of the literature. Sot Sci Med 1984 ; 19 : 93-l 15 I8 Platt S. Clinical and social characteristics of males parasuicides: variation by employment status and duration of unemployment. Acra Psychiatr Stand 1986 ; 74 : 24-3 I 19 Platt S. Parasuicide and unemployment. Br J Psychiatry 1986 ; 17
149:401-405 20 21
22
23
24
Platt S, Kreitman N. Parasuicide and unemployment among men in Edinburgh 1968-82. Psycho1 Med 1985 ; 15 : 113-23 Platt S, Duffy 1. Social and clinical correlates of unemployment in two cohorts of males parasuicide. Sot Psychiatry 1986 ; 21 : 17-24 Platt S. Hawton K, Kreitman N, Fagg J, Foster J. Recent clinical and epidemiological trends in parasuicide in Edinburgh and Oxford: a tale of two cities. Psycho1 Med 1988 ; I8 : 405- I8 Platt S, Kreitman N. Long term trends in parasuicide and unemployment in Edinburgh, 1968-87. Sot Psychiatry Psychiatr Epidemiol 1990 ; 25 : 56-61 Pritchard C. New patterns of suicide by age and gender in the United Kingdom and the Western World 1974-1992; an indicator of social change? Sot Psychiatry Psychiatr Epidemiol 1996 ; 31 :227-34
25
Runeson BS, Beskow J, Waem M. The suicidal process in suicides among young people. Acta Psychiatr Scana’ 1996 ; 93 :
26
Runeson B, Eklund G, Wasserman D. Living conditions of female suicide attempters : a case-control study. Actu Psychiatr Stand 1996 ; 94 : 125-32 Shapiro CM, Parry MR. Is unemployment a cause of parasuitide? BMJ 1984 ; 289 : 1622 Silove D, George G, Bhavani-Sankaram V. Parasuicide: interaction between inadequate parenting and recent interpersonal stress. Aust NZI Psychiatry 1987 ; 21 : 221-8 Van Casteren V, Van Der Veken J. The Belgian sentinel general practitioners as a tool for surveillance of suicide and attempted suicide. Arch Public Heulth 1993 ; 5 I : 267-78 Warr P. Psychological aspects of employment and unemployment. Psycho1 Med 1982 ; 12 : 7-l 1 Wasserman D, Cullberg J. Early separation and suicidal behaviour in the parental homes of 40 consecutive suicide attempters. Acta Psych&r Stand 1989 ; 79 : 296-302
35-42
27 28
29
30 31
Original article
Suicide attempts and job insecurity: a complex association F Chastang l*, P Rioux I, I Dupont2, 1Department
of Psychiatry,
2 Emergency Department, (Department of Psychiatry,
(Received
21 August
E Baranger4,
‘Department Psychiatric
1997; final
version
V Kovess3, E Zariflan
of Public Health, Caen Hospital, 50100 Saint-Lo, 18 May
1998; accepted
University France
9 July
Hospital,
14033
I Caen;
1998)
Summary - Objective: Since Durkheim, epidemiological studies have revealed a significant, complex association between unemployment and suicidal behaviour. The aim of this study was to analyse the relationship between parasuicide and job instability, including unemployment, French social measures against unemployment and occasional work. Method: Demographic data, personal and familial characteristics were collected in 541 suicide attempters. Results: Seventy-seven per cent were socially active, with 61.5% in regular employment, and 38.5% in precarious employment. The femaleto-male ratio approached 2 in the securely employed sample, and fell to 1 for those with poor social and professional integration. Depression, parasuicide, and alcohol abuse were more common in the families of repeaters in secure employment. The impact of the familial psychiatric background was no longer significant in the job insecurity group. Fostering in childhood was a risk factor for repeat suicidal behaviour in the group with job insecurity. B 1998 Elsevier, Paris psychiatric
emergency
/ parasuicide
/job
insecurity
/ epidemiology
INTRODUCTION
Since Durkheim’s studies, a great number of research from various industrial countries have shown suicide to be consistently and significantly associated with unemployment although no causal relationship could be demonstrated [ 171. Cross-sectional studies provide evidence of significantly higher unemployment rates among suicide attempters than in the general population [lo, 11, 17, 19, 20, 21, 221, while ecological studies show a significant, positive association between suicide attempts and unemployment rates in given geographic areas [5]. Most of these studies were carried out in male populations [ 171. A few reported similar findings in female samples ie, higher suicide rates, as well as higher psychiatric morbidity, in unemployed, compared with employed women [ 11, 251. The nature of the relationship between unemployment and suicidal behaviours remains unclear. A straightforward causality is unlikely; more complex interrelations including social status and psychiatric history seem to be at play [ 10, 111.
*Correspondence
and reprints:
Centre
Esquirol,
CHU
C&e de Nacre,
A characteristic of our current social environment is the absence of a clear distinction between those in work and those who are unemployed. A number of people who would consider themselves unemployed are excluded from official statistics, having taken up temporary work. The issues of social and professional integration and job insecurity go beyond the scope of registered unemployment; in France a set of social measures have been taken in an attempt to control unemployment, mainly by setting up a minimal social security allowance for all (RMI: Revenu Minimal d’Insertion), and government-supported, fixed-term (usually 6 month), part-time, unskilled employment contracts (CES: Contrat Emploi Solida&C). CES contracts apply to unemployed people with particularly poor job perspectives, while any person over 25 who is unable to work but prepared to take part in a social or training program can claim RMI benefits. These measures have had little effect so far in terms of unemployment and job prospects,
especially
14033 Caen cedex, France.
with
the young
who
are
360
F Chastang
increasingly faced with job insecurity. The psychological impact of such issues must be emphasised. The current social environment prompted us to emphasise the concept of job insecurity, which for the purpose of this study includes registered unemployment as well as welfare measures against unemployment (RMI and CES) or occasional work. Despite an abundant international research into the relationship between unemployment and suicidal behaviour, to our knowledge there has been no reference so far in the national or international literature on the relationships between suicidal behaviour, especially repeated suicide attempts, and precarious employment status. The aim of this study (which is part of an investigation carried out between 6 December 1993 and 5 June 1994 which concentrates on patients referred to the Emergency Department of Caen University Hospital for psychological problems) is to examine, in socially active subjects, the relationships between suicidal behaviour and job instability defined as above, with special emphasis on: - firstly, characterising first attempters and repeaters in terms of social and professional integration (whether the subject’s current employment is insecure or not); - secondly, determining the impact of personal and familial factors on repeated suicide according to the level of professional integration; - thirdly, identifying the nature of the relationship between repeated suicide and poor professional integration.
et aJ
suicide, depressive disorder, alcohol or substance abuse. The personal history focused on previous psychological problems, with particular emphasis on suicide attempts, and previous psychiatric hospitalisation or follow-up. The item “family history of depression” was assessed with the question: “has a member of family ever been depressed, that is to say felt so low he or she hardly ate, was unable to work or carry out his daily activities, for a period of a few weeks to several months?” [ 131. Psychiatric assessment was done by qualified psychiatrists according to DSM-III-R criteria [2] in the period shortly following the attempt.
Statistical analyses In order to fulfil the aim of the study, suicide attempters with poor job integration were compared with suicide attempters in employment, for both groups of first attempters and repeaters. Statistical analysis was done with the aid of SASo software, using chi 2 tests(and Yates’ corrected chi 2 when necessary) on qualitative variablesand variance analysis on quantitative variables. Overall and stepwise logistic regression were carried out to determine the role of each variable. The logistic model included variables of sex, age, family history of psychiatric disorder, losses or separationsbefore
the ageof 12. RESULTS Characteristics of socially active suicide attempters
MATERIALS
AND METHODS
Subjects Among suicide attempters
aged
15 or over (n = 541) who
were examined in the Emergency Department of the University Hospital in Caen (France) between 6 December 1993
and 5 June 1994 and included in the original survey, 416 (77%) could be classified as socially active. All school attenders, students, retired or disabled excluded from the present study.
people
were thus
Data collection Patients were evaluated using a 113 item hetero-questionnaire, adapted from the instrument used by V Kovess [ 13 1 in general population enquiries, which covered the following topics: - firstly, social, demographic and professional data, housing and lifestyle; - secondly, reasons for referral (especially: attempted suicide), origin of referral, need for psychotropic medication on the emergency ward; - thirdly: family history of separation before the age of 12 (divorce or separation of parents, death of a family member, fostering in unrelated family or an institution), fatal suicide, attempted
The study sample (n = 416, mean age = 33.6 +/- 1 years, female: 59.4%, male: 40.6%) markedly differs from the socially active general population aged over 15 in the Caen area: suicide attempters were more often divorced (17% vs 6%, P < 0.001) and more often unemployed (17% vs 13.6%. P = 0.01). Fifty four per cent were repeaters, with an average of three previous attempts (table I). Among the 416 socially active suicide attempters, 61.5% were in regular employment, and 38.5% in precarious employment. The female-to-male ratio approached 2 in the securely employed sample, and fell to 1 for those with poor social and professional integration, both in first attempters and repeaters. Suicide attempters with poor integration tended to be younger than those securely employed (5 1% aged less than 25 years against 23%, P < 0.01); lack of social support and absence of fixed housing were also more common in this group. As to family background, selfattempters
more
often
came
from
broken
homes
(20.9% vs 11.6%, P = 0.01) had been in foster homes or families in early childhood (13.9% vs 5.X%, P = O.OOS),had family histories of depression (44.7%
Suicide Table I. Comparison between and the socially active general
attempts
the socially active suicide attempters population from the Caen area (%).
Suicide attempters (n = 416)
General population (n = 86462)
Females Males
59.4 40.6
53.9 46. I
129 >30
47.1 52.9
36.6 63.4
Marital sfutus Unmarried Married Widowed Divorced
47. I 30.0 5.0 16.9
43.8 46.8 3.8 6.0
sex
5 0.001***
5 o.ooi***
5.4 2.6 34.6 13.0 44.4
6.5 13.0 17.8 15.3 47.4
Employment status Employment rate Unemployment rate
61.5 17.0
55.6 13.6
***:
P 2 0.001;
Table II. Comparison between ters and suicide attempters (SA)
P
5 0.001***
Sociaffpi-ofessional status Professionals, executives, university lecturers Intermediate status Employees Workers Others
361
and job insecurity
10.001***
securely employed with job insecurity
suicide (%).
attemp-
Securely SA with job employed SA insecurity (n = 256) (n = 160)
P
Early losses Divorce of parents Fostering
11.6 5.8
20.9 13.9
0.01* 0.005*+
Psychiatric family history Suicide Parasuicide Depression Alcohol abuse Antisocial behaviour Substance abuse Other psychiatric disorder
9.6 lb.7 31.7 26.5 5.0 1.3 2.5
15.3 24.8 44.7 35.7 6.4 7.0 3.8
0.15 0.05* 0.02” 0.05* 0.82 0.02’ 0.70
Personal Previous Previous Previous Psychiatric
66.3 50.6 34.3 20.1
75.9 64.6 44.3 27.2
0.04* 0.01** 0.04* 0.09
***:
psychiatric history psychiatric problem suicide attempt psych. hospitalisation follow-up
P IO.001;
**: 0.001 < P IO.01;
*: 0.01 < P 50.05.
~o.OOl* Table III. Securely ween first-attempters
employed suicide attempters: and repeaters (96).
comparison
bet-
**: 0.001 < P < 0.01; *: 0.01 < P IO.05. First-attempters (n = 120)
vs 31.7%, P = 0.02), alcoholism (35.7% vs 26.4%, P = 0.05) and suicidal behaviour (24.8% vs 16.7%, P = 0.05). Personal histories included significant levels of psychiatric morbidity, especially with regard to suicide attempts (64.6% vs 50.6%, P = 0.01) and previous psychiatric hospitalisations (44.3% vs 34.3%, P = 0.04) (table II). Comparing first attempters fessional status
and repeaters
by pro-
In the securely employed group First attempters represented 50% of suicide attempters in secure employment; they did not differ from repeaters in terms of female/male ratio (approximately 2) matrimonial status, level of education or type of housing. They were, on the contrary, significantly younger. Early losses were no more frequent among first attempters than repeaters. Depression, on the other hand, was significantly more common in the families of repeaters in secure employment (37.4% vs 25.6%. P = 0.05). So was suicide attempt (23.6% vs 13.7%, P = O.OOS>, alcohol consumption (34.1% vs 18.1%, P = 0.02), and other mental disorders (9.8% vs 2.6%, P = 0.02). Previous psychiatric hospitalisations
Early losses Divorce of parents Fostering Psychiatric family history Suicide Parasuicide Depression Alcohol abuse Antisocial behaviour Other psychiatric disorder Personal psychiatric history Previous psy hospitalisation Psychiatric follow-up
Repeaters (n = 1.23)
P
8.5 5.1
14.6 6.5
0.13 0.85
11.1 13.7 25.6 18.1 4.3 2.6
8.1 23.6 37.4 34.1 5.7 9.8
0.45 0.05* 0.05* 0.02* 0.60 0.02*
8.3 R.3
58.5 30.9
2 0.001***
(58.5% vs 8.3%, P < 0.001) and patients followed-up by a specialist (30.9% vs 8.8%, P < 0.001) were also more frequent among repeaters (table Iii). The logistic regression demonstrated that alcoholism and perceived depression within the family are risk factors for repeat suicide. Suicide attempters in regular employment were twice as likely to be repeaters if a member of the family was considered
362
F Chastang
Table IV. Suicide attempters with job insecurity: ween first attempters and repeaters (%). Firstuttempters (n = 56) Early losses Divorce of parents Fostering Psychiatric Suicide
family
comparison
Repeaters (n = 102)
bet-
P
14.5 9.1
24.5 16.7
0.18 0.19
16.4 21.8 38.2 34.5 1.8 I .8
14.7 26.5 48.0 36.3 8.8 4.9
0.42 0.80 6.48 0.88 0.06 0.58
history
PdmSUiCide
Depression AIcohoI abuse Antisocial behaviour Other psychiatric disorder
et al
of depression, suicide attempt, alcohol abuse, and other mental disorders in close members of families were also more frequent in this group, although not reaching statistical significance. Repeaters were also more often treated for psychological problems (32.3% vs 17.9%, P = 0.05) or hospitalised for psychiatric reasons (56.9% vs 21.4%, P < 0.001) (table IV). Multivariate analyses using logistic regression demonstrated that the risk of repeated suicide attempts was 8 times higher among suicide attempters who had been fostered by non-related family (or an institution) early in life (table V). DISCUSSION Representativeness
Personal psychiatric history Previous psy hospitalisation Psychiatric follow-up ***:
P < 0.001;
21.4 17.9
**: 0.001 < P IO.01;
56.9 32.3
6 0.001*** 0.05*
*: 0.01 < P 5 0.05.
Table V. Comparison between first attempters results of the logistic regression analysis.
and repeaters:
Securely employed suicide attempters Adj OR [Cl: 9.5%]
Job insecurity suicide attempters Adj OR [Cl: 95%]
Early losses Divorce of parents Fostering
1.79 [0.72; 4.411 0.19 [0.04; 0.941
2.19 [0.77; 6.181 8.06 [1.35;48.10]
Psychiarric family history Parasuicide Depression Alcohol abuse Other psychiatric disorder
0.94 2.07 2.48 2.37
0.94 1.55 0.84 1.24
OR: odds ratio; CI: confidence
[0.43; [ 1.10; [1.23; [0.80;
2.04] 3.891 4.991 1.251
(0.39; 2.251 [OH; 3.761 [0.39; 1.831 [0.30; 2.151
interval.
depressed, and 2.5 times as likely if there was a family history of alcoholism (table V). In the group with job insecurity Repeaters represented 65% of suicide attempters in insecure employment. The female/male ratio was found to be 0.86 in first attempters compared to 1 among repeaters. Repeaters and first attempters were comparable in terms of age, matrimonial status (although divorce was more frequent among repeaters), social support and level of education. More repeaters, on the other hand, had no permanent home, were living in hostels or institutions, or were homeless. Family backgrounds are similar in both groups, especially in terms of losses before age 12. Histories
The characteristics of the population studied, although very different from those of the general population of similar age, are consistent with data from other sources: suicide attempters are more often female, more often young adults, commonly unmarried, widowed or divorced, and more often unemployed. Our own investigation, however, was restricted to referred patients. It is known that between 20% and 30% of suicide attempters do not get referred to a hospital [9, 14, 291. Suicide attempters with poor social and professional integration may be more likely to be directed to hospital. This hypothesis can be related to Barling’s [3] findings, which demonstrated a positive relationship between the admission rate (especially readmission rate) to psychiatric services and the unemployment rate, taken as an index of economic decline. T~F level of job integration could therefore be a factor in the medical decision to hospitalise. Males’
greater
vulnerability
Most studies on the relationships between suicide and unemployment have been restricted to men. We deliberately chose to consider both male and female suicide attempters in our study, this based on evidence from various sources that unemployed females, like their male counterparts, are at an increased risk of suicide 111, 26, 301. Our female/male ratio of 2 in the regularly employed group is in agreement with the literature on suicide [4], while females and males were alm&t equally represented in the poorly integrated group. This finding is close to Hawton’s [ 10, 1 I] who observed a significantly higher risk of suicide in men than women, with a greater difference between males and females for short-term unemployment. Men’s greater vulnerability to job insecurity can probably be related to the traditional image of the male as bread-
Suicide
attempts
winner in our society. Men’s stronger emphasis and higher estimation of their work, abrupt changes in family roles and social references resulting from unemployment, or even reluctance to create a family for fear of unemployment could significantly aggravate signs of psychological distress. A growing number of women, however, could be affected by the adverse psychological effects of job precariousness. This was suggested by recent reports on suicide rates in industrial countries in the years 1974-1992, which demonstrated a rise in suicides rates in females aged 25 to 34 years that equals that among men in the same age-group. The current trend in our society is undoubtedly towards a change in women’s social behaviour, becoming similar to men’s [24], particularly in terms of women’s involvement in their work, and social recognition of this. Poor job integration
and suicidal
behaviour
The concept of “job precariousness” as defined in our study covers registered unemployment, French social programs against unemployment, as well as very short term employment (C 6 months) or moonlighting. It appears of great relevance/very practical, reflecting the difficulties that many people, especially young people, have in finding, or finding again, a job. Fifty per cent of our suicide attempters in precarious job situations were less than 25. They had experienced twice as many family separations before the age of 12 as suicide attempters in regular employment. Psychiatric family antecedents in terms of suicidal behaviour, depression and alcoholism, as well as psychiatric personal antecedents, especially previous suicide attempts, were also significantly more frequent; repeaters represented 64% of suicide attempters in precarious job situations and 50% of those in regular employment. There was no difference between men and women, either in the regularly or the precariously employed. Our findings are in agreement with the literature, which provides evidence of an increased psychiatric morbidity, especially previous suicide attempts, in the unemployed, whether male or female, getting proportionally greater as the duration of unemployment increases [lo, 11, 16, 231. In men, the risk of self-harm after a year’s unemployment was found to be two to five times higher than after a month and 12 to 18 times higher than in regularly employed people [ 10, 18, 201. The same trend was observed in women, unemployment being identified as a factor independent from other living conditions, such as solitude [ 11, 251. The increased risk of suicide in long term unemployment is difficult to interpret. It may be unrelated to unemployment itself, but rather reflect the fact that
and job insecurity
363
psychologically more vulnerable people may get more rapidly and definitely excluded from work [ 101. Poor job integration
and repeated suicide attempts
Our findings suggest that factors potentially influencing repeated suicide attempts vary according to the level of professional and social integration. Suicide attempters in regular employment were found to have the following family risk factors for repeated suicide attempt: previous suicide attempts, perceived depression or addictive behaviours. Such risks factors are in close relationship with the level of family stability and identification processes which have been shown to generate suicidal behaviours, particularly repeated attempts [7, 8,251. By contrast, family antecedents do not seem to have any direct influence on repeated attempts among the poorly integrated, while multivariate analyses identify early fostering as a determinant of repeat suicide in this group. Such complex relationships between unemployment and suicidal behaviour could be accounted for by the existence of a vulnerability factor formed during the childhood. In a cohort study of 2,256 men followed from childhood into adulthood, Montgomery et al [ 151 demonstrated that social and psychological difficulties in childhood were predictive of unemployment of varying duration later in life, this though after adjusting for confounding factors. Moreover, family instability, particularly in early childhood, is a common factor in young suiciders [ 1,6]. Fostering by non-related family or an institution in childhood, which in our study was found to be far more frequent in recidivists with poor professional integration, bears witness to separation from parental figures, as well as to early, severe and prolonged family disruption, the consequences of which are manifold. Lower self-esteem, greater adaptive difficulties at various stages in life, lingering identification process involving absent or disappointing parental images all result in greater psychological vulnerability [28, 311, which in turn accounts for a higher psychiatric morbidity as well as more difficult social and professional integration, the two being interrelated. The early origin of the subject’s vulnerability to life events could explain the absence of a dkect or indirect causal link between suicide and unemployment [12, 271. In a study of unemployed suicide attempters, Shapiro [27] found that only 4% viewed unemployment as directly related to their suicidal behaviour, while 14% explicitly identified family factors as the cause. Family upheaval, particularly role changing due to unemployment, as well as resulting social and familial diffrculties, could be experienced as a reminiscence of early family instability in childhood.
F Chastang
364
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35-42
27 28
29
30 31