- Email: [email protected]
Suicide, recession, and unemployment – Authors' reply
Correspondence
3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece (KNF, MS); Evaggelismos General Hospital, Athens, Greece (SAK); Social Cooperative “New Horizons”, Corfu Mental Health Sector, Corfu, Greece (SAK); Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece (IAG); Open University of Cyprus, Cyprus, Greece (PNT); and Social Cooperative, 8th Athens Mental Health Sector, Athens, Greece (PNT) 1
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Reeves A, Stuckler D, McKee M, Gunnell D, Chang SS, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012; 380: 1813–14. WHO. Suicide rates (per 100,000), by gender, Argentina. http://www.who.int/mental_ health/media/arge.pdf (accessed Feb 19, 2013). WHO. Suicide rates (per 100,000), by gender, Hungary. http://www.who.int/mental_health/ media/hung.pdf (accessed Feb 19, 2013). WHO. Suicide rates (per 100,000), by gender, Ukraine (accessed Feb 19, 2013). WHO. Figures and facts about suicide. http:// whqlibdoc.who.int/hq/1999/WHO_MNH_ MBD_99.1.pdf (accessed Feb 19, 2013). Hassan R. Effects of newspaper stories on the incidence of suicide in Australia: a research note. Aust N Z J Psychiatry 1995; 29: 480–83. Etzersdorfer E, Sonneck G, Nagel-Kuess S. Newspaper reports and suicide. N Engl J Med 1992; 327: 502–03.
Authors’ reply Mindaugas Stankunas and colleagues suggest that the Baltics did not experience a rise in suicides during the 2008 recession. Yet, as their data show, suicide rates did rise between 2007 and 2009 in the Baltic states, increasing by 11% in Lithuania and 16% in Latvia, for example—reversing earlier steep declines. Konstantinos Fountoulakis and colleagues continue to dispute evidence from multiple independent researchers of a role for recessions and unemployment in suicide.1 In doing so, they disregard clear evidence that the rise in US suicide rates after the recession is a significant deviation from past trends, unlike earlier nonsignificant year-to-year variations. Their observation that suicides rose before unemployment ignores microlevel and macro-level analyses that show the importance of anticipation of job loss,2 as well as our statements that unemployment is only one of the factors that increase suicide in a recession, with others, such as the 722
rise in personal debt and mortgage foreclosures (which occur before rises in unemployment), also affecting mental health.3 Fountoulakis and colleagues cite case studies indicating that suicides did not rise during recessions (ie, Ukraine, Argentina, and Hungary). Yet, similar to the Baltics, suicides in Ukraine increased over and above long-term trends starting in 2007.4 Argentinian data, as cited by Fountoulakis and colleagues, actually suggest an increase in suicide after the 1999–2002 recession compared with the previous downward trend.5 In Hungary, there has been a rise in the suicide rate corresponding to the threat of, and subsequent rise in, unemployment between 2007 and 2009.6 Given strong evidence that economic recession is a risk factor for suicide, as now independently verified by the US Centers for Disease Control and Prevention,7 and that rising unemployment accounts for a sizeable proportion of these excess suicides,8 we believe that the priority for public health researchers should now be to understand how some countries, such as Sweden and Finland, have managed to mitigate increases in suicides after marked economic recessions, whereas others, such as Greece, have not.9 We declare that we have no conflicts of interest.
*Aaron Reeves, David Stuckler, Martin McKee, David Gunnell, Shu-Sen Chang, Sanjay Basu [email protected] University of Cambridge, Cambridge CB2 3RQ, UK (AR, DS); London School of Hygiene and Tropical Medicine, London, UK (DS, MM, SB); University of Bristol, Bristol, UK (DG, S-SC); HKJC Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong SAR, China (S-SC); and Stanford Prevention Research Center, Department of Medicine, Stanford University, Palo Alto, CA, USA (SB) 1
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Platt S, Hawton K. Suicidal behaviour and the labour market. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: John Wiley & Sons, 2000: 309–84. Perlman F, Bobak M. Assessing the contribution of unstable employment to mortality in posttransition Russia: prospective individual-level analyses from the Russian longitudinal monitoring survey. Am J Public Health 2009; 99: 818–25.
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Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. Eur J Public Health 2013; 23: 103–08. WHO. WHO European health for all database. http://data.euro.who.int/hfadb/ (accessed Feb 19, 2013). Liu K-Y. Suicide rates in the world: 1950–2004. Suicide Life Threatening Behav 2009; 39: 204–13. Duleba T, Gonda X, Rihmer Z, Dome P. Economic recession, unemployment and suicide [Gazdasági világválság, munkanélküliség és öngyilkosság]. Neuropsychopharmacol Hung 2012; 14: 41–50. Luo F, Florence CS, Quispe-Agnoli M, Ouyang L, Crosby AE. Impact of business cycles on US suicide rates, 1928–2007. Am J Public Health 2011; 101: 1139–46. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012; 380: 1813–14. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315–23.
We would like to contribute to the lively debate on the supposed association between the current economic crisis and national suicide rates.1 Here we supply Hungarian data. Hungarian annual suicide rates were tremendously high in the previous century and characterised by long-lasting and monotonic trends. Accordingly, there was a zenith during the Great Depression (1929–33), with values above 30 per 100 000 per year. Afterwards, annual rates decreased until 1955 (below 20 per 100 000 per year) then increased until the mid1980s (about 45 per 100 000 per year). From 1987, the rate showed a marked decline and reached the value 24·4 per 100 000 per year in 2006, when the strong declining trend of the previous 20 years stopped. Since then—until 2011—the annual suicide rates remained steady.2–4 Data on Hungarian unemployment are available from 1993.5 The unemployment rate steadily decreased between 1993 (11·9%) and 2001 (5·7%). From 2002 to 2004 the rates were similar (table). The rate rose to 7·2% in 2005 and remained steady—with small oscillations— until 2008. The effect of the current economic crisis on unemployment www.thelancet.com Vol 381 March 2, 2013
3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece (KNF, MS); Evaggelismos General Hospital, Athens, Greece (SAK); Social Cooperative “New Horizons”, Corfu Mental Health Sector, Corfu, Greece (SAK); Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece (IAG); Open University of Cyprus, Cyprus, Greece (PNT); and Social Cooperative, 8th Athens Mental Health Sector, Athens, Greece (PNT) 1
2
3
4 5
6
7
Reeves A, Stuckler D, McKee M, Gunnell D, Chang SS, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012; 380: 1813–14. WHO. Suicide rates (per 100,000), by gender, Argentina. http://www.who.int/mental_ health/media/arge.pdf (accessed Feb 19, 2013). WHO. Suicide rates (per 100,000), by gender, Hungary. http://www.who.int/mental_health/ media/hung.pdf (accessed Feb 19, 2013). WHO. Suicide rates (per 100,000), by gender, Ukraine (accessed Feb 19, 2013). WHO. Figures and facts about suicide. http:// whqlibdoc.who.int/hq/1999/WHO_MNH_ MBD_99.1.pdf (accessed Feb 19, 2013). Hassan R. Effects of newspaper stories on the incidence of suicide in Australia: a research note. Aust N Z J Psychiatry 1995; 29: 480–83. Etzersdorfer E, Sonneck G, Nagel-Kuess S. Newspaper reports and suicide. N Engl J Med 1992; 327: 502–03.
Authors’ reply Mindaugas Stankunas and colleagues suggest that the Baltics did not experience a rise in suicides during the 2008 recession. Yet, as their data show, suicide rates did rise between 2007 and 2009 in the Baltic states, increasing by 11% in Lithuania and 16% in Latvia, for example—reversing earlier steep declines. Konstantinos Fountoulakis and colleagues continue to dispute evidence from multiple independent researchers of a role for recessions and unemployment in suicide.1 In doing so, they disregard clear evidence that the rise in US suicide rates after the recession is a significant deviation from past trends, unlike earlier nonsignificant year-to-year variations. Their observation that suicides rose before unemployment ignores microlevel and macro-level analyses that show the importance of anticipation of job loss,2 as well as our statements that unemployment is only one of the factors that increase suicide in a recession, with others, such as the 722
rise in personal debt and mortgage foreclosures (which occur before rises in unemployment), also affecting mental health.3 Fountoulakis and colleagues cite case studies indicating that suicides did not rise during recessions (ie, Ukraine, Argentina, and Hungary). Yet, similar to the Baltics, suicides in Ukraine increased over and above long-term trends starting in 2007.4 Argentinian data, as cited by Fountoulakis and colleagues, actually suggest an increase in suicide after the 1999–2002 recession compared with the previous downward trend.5 In Hungary, there has been a rise in the suicide rate corresponding to the threat of, and subsequent rise in, unemployment between 2007 and 2009.6 Given strong evidence that economic recession is a risk factor for suicide, as now independently verified by the US Centers for Disease Control and Prevention,7 and that rising unemployment accounts for a sizeable proportion of these excess suicides,8 we believe that the priority for public health researchers should now be to understand how some countries, such as Sweden and Finland, have managed to mitigate increases in suicides after marked economic recessions, whereas others, such as Greece, have not.9 We declare that we have no conflicts of interest.
*Aaron Reeves, David Stuckler, Martin McKee, David Gunnell, Shu-Sen Chang, Sanjay Basu [email protected] University of Cambridge, Cambridge CB2 3RQ, UK (AR, DS); London School of Hygiene and Tropical Medicine, London, UK (DS, MM, SB); University of Bristol, Bristol, UK (DG, S-SC); HKJC Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong SAR, China (S-SC); and Stanford Prevention Research Center, Department of Medicine, Stanford University, Palo Alto, CA, USA (SB) 1
2
Platt S, Hawton K. Suicidal behaviour and the labour market. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: John Wiley & Sons, 2000: 309–84. Perlman F, Bobak M. Assessing the contribution of unstable employment to mortality in posttransition Russia: prospective individual-level analyses from the Russian longitudinal monitoring survey. Am J Public Health 2009; 99: 818–25.
3
4
5 6
7
8
9
Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. Eur J Public Health 2013; 23: 103–08. WHO. WHO European health for all database. http://data.euro.who.int/hfadb/ (accessed Feb 19, 2013). Liu K-Y. Suicide rates in the world: 1950–2004. Suicide Life Threatening Behav 2009; 39: 204–13. Duleba T, Gonda X, Rihmer Z, Dome P. Economic recession, unemployment and suicide [Gazdasági világválság, munkanélküliség és öngyilkosság]. Neuropsychopharmacol Hung 2012; 14: 41–50. Luo F, Florence CS, Quispe-Agnoli M, Ouyang L, Crosby AE. Impact of business cycles on US suicide rates, 1928–2007. Am J Public Health 2011; 101: 1139–46. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012; 380: 1813–14. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315–23.
We would like to contribute to the lively debate on the supposed association between the current economic crisis and national suicide rates.1 Here we supply Hungarian data. Hungarian annual suicide rates were tremendously high in the previous century and characterised by long-lasting and monotonic trends. Accordingly, there was a zenith during the Great Depression (1929–33), with values above 30 per 100 000 per year. Afterwards, annual rates decreased until 1955 (below 20 per 100 000 per year) then increased until the mid1980s (about 45 per 100 000 per year). From 1987, the rate showed a marked decline and reached the value 24·4 per 100 000 per year in 2006, when the strong declining trend of the previous 20 years stopped. Since then—until 2011—the annual suicide rates remained steady.2–4 Data on Hungarian unemployment are available from 1993.5 The unemployment rate steadily decreased between 1993 (11·9%) and 2001 (5·7%). From 2002 to 2004 the rates were similar (table). The rate rose to 7·2% in 2005 and remained steady—with small oscillations— until 2008. The effect of the current economic crisis on unemployment www.thelancet.com Vol 381 March 2, 2013