Background
Methods
Search strategy and definition of terms
Eligibility criteria and data extraction
Mental health outcomes associated with economic recessions
Results
Study selection results
Research designs
Studies research design | |
Case–control | 2 |
Cohort | 30 |
Cross-sectional | 41 |
Ecological | 28 |
Samples | |
Cross-national population samples | 16 |
National population samples | 66 |
Regional/community samples | 19 |
Geographical allocation of studies’ samples | |
EU | 61 |
North America (USA and Canada) | 18 |
Australasia (Australia and New Zealand) | 7 |
Asia (China, Japan, South Korea) | 6 |
South America (Argentina and Brazil) | 2 |
Multicentre | 7 |
Samples and geographical allocation
Pre and post-economic recession changes in psychological wellbeing
Study | Setting | Study design | N Year Age | Socioeconomic determinants | Mental health outcomes | Associations/Effects | Strengths | Limitations |
---|---|---|---|---|---|---|---|---|
[28] | National population sample, Greece | Cohort | 17,713 (2008–2013) Mean age 39.41y (SD = 8.83) | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Employment Status | Psychological Well-being Mental health (CES-D scale) Self-rated health | In the period 2008–2013 unemployed people faced more impaired health (3.21 vs 2.48, t = 8.34, p = 0.00) and mental health than did employed people (12.67 vs 9.39, t = 12.28, p =0.00). These health differences between unemployed and employed individuals were smaller in 2008–2009 than in 2010–2013. | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time, producing stronger causal conclusions. The results indicate a relationship between unemployment and health/mental health. | The impact of economic recessions varies across cultures and time periods; thus, the generalisability of the findings may be considerably limited by the uniqueness of the Greek situation. |
[29] | National population sample, Italy | Cohort | 37,782 (2006–2010) 15–64 y | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Employment Status | Psychological Well-being Self-rated health | Temporary workers, first job seekers and unemployed individuals all perceive their health as being worse than permanent workers do. The health inequalities between permanent workers and the unemployed rose, especially for males and young people, after the economic recession. | The temporal order of the exposures, confounders, and the outcome under consideration affected all the participants at the same time, producing stronger causal conclusions. | The impact of economic recessions varies across cultures and time periods; thus, generalising findings may be reasonably limited by the uniqueness of the Italian social system. |
[31] | National population samples from Greece and Poland | Repeated cross-sectional Case–control | 54,120 cases 136,952 controls (2006–2009) | Inter-time Variables Pre- and post-recession period | Psychological Well-being Self-reported health | Relative to the control population (Poland), Greece experienced a significantly bigger increase in the odds of poor health after the crisis (OR = 1.16; 95 % CI 1.04–1.29) | This study benefits from having a control group and cross-national design. The study is composed of comparable surveys across two time points, before and after the onset of the recession. | Its cross-sectional design removes the possibility of causal inference. Data is derived from 2006–2009 and the crisis started in 2008 so the long-term effects of the recession could not be investigated. |
[30] | National population sample, Greece | Repeated cross-sectional | 10,572 (2006) (2011) >18 years | Inter-time Variables Pre- and post- recession period | Psychological Well-being Self-reported health | Self-reported good health deteriorated from 71 % in 2006 to 68.8 % in 2011 (P < 0.05). | The study is composed of comparable surveys across two time periods (pre- and post-recession). | Its cross-sectional design removes the possibility of causal inference. It is limited to 2011. |
[32] | National population sample, England, UK | Repeated cross-sectional | 106,985 (1991) (2010) 25–64 y | Inter-time Variables Pre- and post- recession period | Psychological Well-being Mental health distress (GHQ-12) | Age-sex adj GHQ-12 caseness increased from 13.7 % (95 % CI:12.9–14.5 %) in 2008 to 16.4 % (95 % CI:14.9–17.9 %) in 2009 and 15.5 % (95 % CI:14.4–16.7 %) in 2010. Women only had a greater prevalence from 1991 until the recession, but men showed an increase over the period. | Uses a continuous measure of mental health symptoms. Large nationally representative dataset surveyed two times. | Its cross-sectional design removes the possibility of causal inference. Limited period of time; the long-term effects of the recession could not be investigated. |
[33] | National population sample, Spain | Repeated cross-sectional | 23,760 (2006) 16,616 (2012) | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Employment Status | Psychological Well-being Mental health distress (GHQ-12) | Results found an increase in the prevalence of poor mental health among men (prevalence ratio = 1.15, 95 % CI 1.04–1.26], especially among those aged 35–54 years, and a slight decrease for women between 2006/07 and 2011/12. There was a larger impact among the unemployed. | The study is composed of comparable surveys across two time points before and after the economic recession period. Representative sample | Its cross-sectional design removes the possibility of causal inference. Limited period of time (2012); the long-term effects of the recession could not be investigated. |
[34] | Regional population sample, Working-age women, Stockholm, Sweden | Repeated cross-sectional | 27,994 (2006) 22,639 (2010) 18–64 y | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Employment Status | Psychological Well-being Mental health distress (GHQ-12) | Mental distress increased among women of all types of employment status between 2006 and 2010, but more so among unemployed women, OR 2.65 (CI 95 % 2.17–3.23) in 2006 and OR 2.81 (CI 95 % 2.20–3.58) in 2010. | The study is composed of comparable surveys across multiple time points before and after the economic recession period. | Its cross-sectional design removes the possibility of causal inference. Data is derived from 2006–2010 and the crisis started in 2008, so the long term effects of the recession could not be investigated. The sample is composed only of women. |
[35] | National population sample, Japan | Repeated cross-sectional | 168,801 (1986–1989) 150,016 (1998–2001) 20–60 y | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Employment status/Income | Psychological Well-being Self-reported health | The OR for poor self-rated health (95 % CI) among middle-class people compared with the highest class was 1.02 (0.92–1.14) before the crisis and increased to 1.14 (1.02–1.29) after the crisis (p = 0.02). The association was stronger among males. Unemployed people were twice as likely to report poor health. | The study is composed of comparable surveys across multiple time points before and after the economic recession period, showing reports of increased poor health across all socioeconomic statuses. | Its cross-sectional design removes the possibility of causal inference. The study lacks individual-level information on job insecurity, work overload, or pay cuts that can work as confounders. The outcome was self-reported. |
[36] | National population sample, Iceland | Cohort | 9807 (2007) 5439 (2009) | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Employment Status | Common Mental Disorders Psychological stress (PSS-4) | Age-adj stress levels increased between 2007 and 2009 (P = 0.004), only for women (P = 0.003). The OR for high stress levels increased only among women (OR = 1.37), especially those who were unemployed (OR = 3.38), students (OR = 2.01), with middle levels of education (OR = 1.65), or in the middle income bracket (OR = 1.59). | This study examines the longitudinal interrelations between employment status and socio-demographic in psychological stress levels during a period of extensive macroeconomic changes. | The impact of economic recessions varies across cultures and time periods; thus, the generalisability of the findings may be reasonably limited by the uniqueness of Icelandic culture, as well as the nature of the 2008 economic collapse in Iceland. |
[37] | National population sample, Greece | Repeated cross-sectional | 2197 (2008) 2256 (2011) 18–69 y | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Perceived financial strain | Common Mental Disorders Depression (SCID-I) | The odds of major depression were greater in 2011 than in 2008 (OR = 2.6, 95 % CI = 1.97–3.43). Financial strain independently and significantly predicts the presence of major depression (OR = 1.2, 95 % CI = 1.13–1.24). | The study is composed of comparable surveys across two time points before and after the period of the economic recession. | Its cross-sectional design removes the possibility of causal inference. Limited period of time; the long-term effects of the recession could not be investigated. Telephone survey. |
[38] | National population sample, Greece | Repeated cross-sectional | 2197 (2008) 2192 (2009) 18–69 y | Inter-time Variables Psychosocial/economic indicators Pre- and post- recession period Financial strain | Common Mental Disorders Major depressive episode–MDE (SCID-I) | The one-month prevalence of MDE in 2009 was found to be 6.8 %, compared to rates of 3.3 % in 2008 (p < 0.0001). Respondents facing serious economic hardship were at higher risk of developing an MDE. | Representative samples and comparable surveys across two time points before and during the period of the economic recession in Greece. | No causal inference can be made because of the cross-sectional nature of the study. The generalisability of the findings is limited by the uniqueness of the 2008 economic collapse in Greece. Limited period of time; the long-term effects of the recession could not be investigated. |
[39] | National population sample, patients attending primary care centres, Spain | Repeated cross-sectional | 7640 (2006–07) 5876 (2010–11) | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Employment status, Mortgage payments | Common Mental Disorders Substance Disorders Depression Anxiety Somatoform Alcohol-related disorders | Since the pre-crisis period (2006), major depression increased by 19.4 %, anxiety by 8.4 %, somatoform disorders by 7.3 %, and alcohol-related disorders by 4.6 %. The risk of depression when unemployed was OR = 2.12, p < 0.001. The risk of depression resulting from mortgage payment difficulties was OR = 2.95, p < 0.001. | The study is composed of comparable surveys across multiple time points before and after the economic recession period. | Its cross-sectional design removes the possibility of causal inference. Limited period of time; the long-term effects of the recession could not be investigated. Only patients attending and able to access primary care were investigated. |
[40] | Regional working population sample, Alberta, Canada | Repeated cross-sectional | 3579 (2008–2009) | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period | Common Mental Disorders Major depressive disorder (MDD) Dysthymia Anxiety (CIDI) | The 12-month prevalence of major depressive disorder (MDD) before September 1, 2008; between September 1, 2008, and March 1, 2009; and between March 1, 2009, and October 30, 2009, was 5.1, 6.8, and 7.6 % (P = 0.03), respectively. The lifetime prevalence of dysthymia reported during the 3 periods was 0.4, 0.7, and 1.5 % (P = 0.006), respectively. No changes in the 12-month prevalence of social phobia, panic disorder, and generalized anxiety disorder were found over time. | This study examines changes in the population prevalence of common mental disorders before and during the period of the economic recession. | No causal inference can be made because of the cross-sectional nature of the study. The effects of socioeconomic variables were not adjusted. The long-term effects of the recession could not be investigated. |
[41] | National population sample, Hong Kong, China | Repeated cross-sectional | 3016 (2007) 2011 (2009) 15–65 y | Inter-time Variables Psychosocial/economic indicators Pre- and post-economic crisis period Socioeconomic/Employment Status | Common Mental Disorders Major depressive episode (MDE) | The 12-month prevalence of MDE was significantly higher in 2009 (/12.5 %) than 2007 (8.5 %). The prevalence of MDE in the unemployed group increased from 2007 (14.6 %) to 2009 (17.8 %). | The study is composed of comparable surveys across two time points before and after the period of the economic recession. | Because of population characteristics and cultural norms concerning response to economic adversity, the findings may not generalise to other societies. Its cross-sectional design removes the possibility of causal inference. The long-term effects of the recession could not be investigated. |
[42] | National population sample, USA | Cohort | 2,050,431 (2006–2007; 2008–2009) >18 y | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Employment status | Substance-Disorders Alcohol use | The prevalence of any alcohol use significantly declined from 52.0 % in 2006–2007 to 51.6 % in 2008–2009. There was an increase in the prevalence of frequent bingeing, from 4.8 % in 2006–2007 to 5.1 % in 2008–2009 (P < 0.01). Unmarried non-Black men under 30 years who recently became unemployed were at the greatest risk of frequent bingeing. | Large representative sample. Longitudinal measures on changes of alcohol use prevalence during a period of economic recession. | The generalisability of the findings may be reasonably limited to the country’s own policy regarding alcohol use and the social welfare system. Limited period of time; the long-term effects of the recession could not be investigated. |
[43] | Community sample, province and city of Buenos Aires, Argentina | Cross-sectional | 1000 (2002) 18–65 y | Inter-time Variables During recession period | Substance-Disorders Patterns of drinking behaviour Drinking-related problems (Genacis) | During the economic crisis people drank more at home or at friends’ homes. A large number of respondents also reported that people had changed to cheaper or lower-quality alcoholic drinks. | Brings evidence on how the economic crisis is possibly resulting in increased drinking of cheaper or lower-quality alcoholic drinks. | No causal inference can be made because of the cross-sectional design. The validity of self-reports of sensitive behaviours, such as alcohol consumption. Because of the uniqueness of the Argentinean economic collapse and societal characteristics, the generalisability of the findings may be reasonably limited. |
[44] | National population sample, Sweden | Cohort | 4,224,210 (1992–1996) | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Employment status | Suicidal Behaviours Excess mortality effects (suicide) | During the recession there was no additional risk of mortality as a result of suicide. During the post-recession period, there was an additional risk of mortality through suicide for unemployed men (HR = 1.43; 95 % CI = 1.31, 1.56) but not unemployed women. | This study examines longitudinal changes in suicide mortality during a period of mass unemployment in Sweden. Reports post-recessionary increases on suicide among unemployed men, considering possible time-lagged effects. | This research study fails to determine if mental health declined as a result of unemployment, or loss of benefits or income over time. The generalisability of the findings may be limited by the uniqueness of the Swedish welfare system and its economic recession. |
[45] | National population sample, Greece | Repeated cross-sectional | 2192 (2009) 2256 (2011) | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Financial strain (Index of Personal Economic Distress) | Suicidal Behaviours Suicidal ideation Suicide attempts | The rate of suicidal ideation increased from 5.2 % in 2009 to 6.7 % in 2011 (χ
2 = 3.92, df = 1, p = 0.04). The increase was significant in men (7.1 vs. 4.4 %, χ
2 = 6.41, df = 1, p = 0.011) and those aged 55–64 years (7.2 vs. 1.9 %, χ
2 = 14.41, df = 1, p < 0.001), while it decreased in those younger than 24 years (4.9 vs. 13.9 %, χ
2 = 15.83, df = 1, p < 0.001). Suicidal ideation increased among psychotropic medication users (22.7 vs. 4.5 %, χ
2 = 11.10, df = 1, p < 0.001) and those asking for mental healthcare (17.3 vs. 8.3 %, χ
2 = 13.36, df = 1, p < 0.001). No unemployed respondent reported a suicide attempt in 2009, while the proportion was 4.4 % in 2011 (χ
2 = 4.12, df = 1, p = 0.042). | Representative sample. This study provides evidence on the increase in the prevalence of suicidal ideation and reported suicide attempts in a country facing a deep economic recession. | Reported suicidal ideation and suicide attempts can be susceptible to recall bias or to reluctance on the part of respondents to disclose such sensitive information. No causal inference can be made because of the cross-sectional nature of the study. Limited period of time; the long-term effects of the recession could not be investigated. The generalisability of the findings may be reasonably limited by the uniqueness of the 2008 economic collapse in Greece. |
[46] | National population sample, South Korea | Repeated cross-sectional | 27,745 (1998) 27,413 (2001) 25,487 (2005) 3335 (2007) >19 y | Inter-time Variables Psychosocial/economic indicators Pre- and post-recession period Socioeconomic inequalities | Common Mental Disorders Suicidal Behaviours Depression (doctor-diagnosed) Suicidal ideation Suicide attempts | The pro-rich inequalities in the prevalence of depression, suicidal ideation and suicide attempts doubled between 1998 and 2007. The CI for depression decreased from −0.126 (SE: 0.068) in 1998 to −0.278 (SE: 0.068) in 2001 and stayed constant. The CI for suicidal ideation fell gradually: −0.138 (SE: 0.012) in 1998 and −0.250 (SE: 0.028) in 2007. The CI for suicide attempts increased from −0.221 (SE: 0.062) in 1998 to −0.175 (SE: 0.075) in 2001 and −0.179 (SE: 0.089) in 2005, and in 2007 to −0.400 (SE: 0.116). | Nationally representative survey data sets The study is composed of comparable surveys across several time points before and after the period of the economic recession. | Reported suicidal ideation and suicide attempts can be susceptible to recall bias or to reluctance on the part of respondents to disclose such sensitive information. Depressed individuals in lower income groups might have been under-represented because of financial difficulties in seeking professional help. No causal inference can be made as it is a cross-sectional study. |
[47] | National Population sample, Spain | Ecological study | (2005–2010) | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours National suicide rates | An 8.0 % increase was found in the suicide rate above the trend since the financial crisis (95 % CI: 1.009–1.156; P = 0.03). Stratified analyses suggested that the association between the crisis and suicide rates is greatest in males and those of working age. | Uses stratified analyses and adjusted for seasonal fluctuations. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[48] | Regional population sample, Andalusia, Spain | Ecological study | 24,380 (2003–2012) | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours Hospital records on suicide attempts | Compared to the historical trends prior to the onset of the crisis, between 2008 and 2012 there were 4989 more suicide attempts (95 % CI: 1985–8013): 2017 (95 % CI: 87–3987) in men and 2972 (95 % CI: 1878–4075) in women. In men, an association between unemployment and suicidal behaviour was found. | First ad hoc study of the impact of the recession on suicide attempts in Spain based on hospital records in a large population sample. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[49] | Regional population sample, Andalusia, Spain | Ecological study | 1975–2012 | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours Regional suicide rates | Suicide rates have increased since 1975.in recent decades, an upward trend has been observed in young people (15 to 44 y), an annual percentage rate change of 1.21 (95%CI: 0.7–1.7) for men and 0.93 (95 % CI: 0.4–1.4) for women. | Regional trend analysis of the variation in suicide rates. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[50] | National population sample, Italy | Ecological study | (1980–2010) >15 y | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours National suicide rates | The suicide rate for men involved in the labour force increased by 12 % in 2010 compared with that in 2006. The suicide rate declined for women of all ages and for men younger than 25 and older than 65 years of age. | Examined trends in the total official suicide rate before and after the onset of the recession. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. There were no economic variables involved in the analyses. |
[51] | National population sample, England, UK | Ecological study | 2008–2010 | Inter-time Variables Macroeconomic indicators Pre- and post-recession period Regional unemployment rate | Suicidal Behaviours National suicide rates | During 2008 and 2010, there were 846 more (95 % CI: 818–877) suicides among men and 155 (121–189) more suicides among women than would have been expected on the basis of historical trends. The 10 % increase in men’s unemployment was significantly associated with an increase of 1.4 % (0.5–2.3 %) in suicides. | Examined trends in the total suicide rate before and after the onset of the recession and in relation to unemployment rates. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[52] | National population sample, England and Wales, UK | Ecological study | (2001–2011) 16–64 y | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours National Suicide Rates | The downward trend in the suicide rate for men stopped for men aged 16–34 years in 2006 (95 % CI Quarter 3 (Q3) 2004, Q3 2007 for 16–24-year-olds & Q1 2005, Q4 2006 for 25–34-year-olds). The suicide rate in 35–44-year-old men reversed from a downward to an upward trend in early 2010 (95 % CI Q4 2008, Q2 2011). No clear evidence of an association between trends in female suicide rates and indicators of economic recession was found. | Used age- and sex-specific trends in suicide in the years before and after the economic recession of 2008 in relation to a variety of indicators of recession effects. Excluded accidental deaths | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[53] | Cross-national population samples, EU, Canada and USA | Ecological study | 2001–2011 | Inter-time Variables Pre- and post-recession period | Suicidal Behaviours National suicide rates | In the EU, there was a rise in the suicide rate of 6.5 % above past trends in 2009. In Canada, suicides rose by 4.5 % between 2007 and 2009. In the USA, suicides rose by 4.8 % between 2007 and 2010. | Cross-national analysis. Examined trends in the total official suicide rate before and after the onset of the recession. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. Suicide rates may vary across nations for cultural reasons. |
[54] | National population sample, USA | Ecological study | 1999–2010 | Inter-time Variables Macroeconomic indicators Pre- and post-recession period State-level unemployment rate | Suicidal Behaviours National suicide rate | The suicide rate accelerated after the onset of the recession. There were an additional 0.51 deaths per 100,000 per year (95 % CI 0•28–0•75) in 2008–10 – an additional 1580 suicides per year (95 % CI 860–2300). A 1 % rise in unemployment is associated with a 0.99 % increase in the suicide rate (95 % CI 0 · 60–1 · 38, p < 0 · 0001) | Examined trends in the total suicide rate before and after the onset of the recession and in relation to unemployment rates. | Because of its ecological nature, the quality of the data is not assessable and no implications can be drawn regarding causality. The results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
Pre and post-economic recession changes in rates of common mental disorders
Pre and post-economic recession changes in substance-related disorders
Pre and post-economic recession changes in suicidal behaviours
Macroeconomic indicators associated with mental health outcomes
Study | Setting | Study design | N Year Age | Socioeconomic determinants | Mental health outcomes | Associations/Effects | Strengths | Limitations |
---|---|---|---|---|---|---|---|---|
[55] | National population sample, USA | Cohort | 26,313 18–59 y | Macroeconomic indicators State level unemployment rate | Psychological Well-being Health Related Quality of Life, Mental Health Component Summary Scale - (SF-12 Health Survey) | Increases in average state unemployment rate worsen individual’s HRQL. During hard economic times mental health decreases more than physical health | Temporal order of exposures under consideration affected all participants at the same time producing stronger causal conclusions. | The effect sizes are relatively small in magnitude. The results and recommendations should not be generalized to other cohorts. |
[56] | National population sample, Britain, UK | Cohort | 10,264 (1991–2008) 16–65 y | Macroeconomic indicators Local area unemployment rate | Psychological Well-being Mental health distress (GHQ-12) | Mental distress levels among unemployed people are significantly higher than among their securely employed counterparts (2.20; 95 % CI:1.98–2.42). Residence in a high-unemployment area protects against distress if unemployed. | Annual data collected over a 17 year period. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Possible bias due to selection effects threat causal inference since those with poor mental health are more likely to subsequently become unemployed. |
[57] | National unemployed population sample, Sweden | Cohort | 1806 (1996) 1415 (1997) 19–64 y | Macroeconomic indicators Regional unemployment and vacancy rate | Psychological Well-being Mental health distress (GHQ-12) | Significant negative effects of both unemployment rate (−0.22) and vacancy rate (−5.29) on the level of mental health among the unemployed. | Dataset surveyed in two times and shows that higher municipal vacancy rates improved mental health among the unemployed | The cross-sectional result of vacancy rates by longitudinal analysis of change gives some information on this being an effect of ecological modification and not differential health-based selection. |
[59] | National population sample of working-age men, USA | Repeated cross-sectional | 30,000 (1997) 35,000 (2001) | Macroeconomic indicators Local area unemployment rate | Psychological Well-being Mental health distress caseness (K6) | 1 percentage point increase in the local unemployment rate leads to 3.4, 3.3, 2.5, 3.5, 3.5 and 3.8 percentage point increases in responding affirmatively to sadness, hopelessness, worthlessness, restlessness, nervousness, and feelings of effort, respectively. | Gives systematic evidence of the procyclical nature of mental health, in several clusters. | Does not take into account the lagged effect of macroeconomic conditions on mental health. Its cross-sectional design removes the possibility of causal inference. |
[58] | Cross-national, 40 European and Anglo-Saxon societies | Ecological study | 42,275 (2000–2004) (2005–2007) | Macroeconomic indicators Employment status, GDP, income inequality | Psychological Well-being Life satisfaction | Unemployment lowers substantially the level of life-satisfaction (−0.761 to −0.785 points lower than those employed). GDP per capita and income inequality negatively influence this association. | Large cross-national sample with attention to the macroeconomic variables of countries. | Not all contexts that affect the relationship between unemployment and life-satisfaction may be placed at the national level. |
[60] | Regional population sample, Asturias, Spain | Ecological study | 2000–2010 | Macroeconomic indicators National unemployment rate, GDP | Psychological Well-being hospital records on incidence and prevalence of mental illness | Found a negative correlation of unemployment rate with mental health care demand. Unemployment rate was associated with a decrease in both new and prevalent mental health demand. | Regionally analysis of the association between mental health care demand and the variation of the unemployment rate and GDP. | The series studied ended in 2010, just before the intense years of the crisis. Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution. |
[61] | Cross-national samples of 30 countries EU, North American and Australia | Ecological study | 1960–2012 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | Unemployment rate increase has a detrimental impact on suicide, especially in country groups with the least developed unemployment protection (eastern and southern Europe). | Large cross-national sample covering a period of 52 years. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[62] | Cross-national samples, 29 EU countries | Ecological study | 1999–2010 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | A 1 % increase in unemployment rates, suicide rates increase by 0.09. Male suicides increase by 0.21 (per 100,000 male inhabitants). The relationship is positive for women but not statistically significant. | Cross-national level trends analysis covering the period of recession. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[63] | Cross-national samples of 26 EU countries | Ecological study | 1970–2007 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours Substance-Disorders National suicide rates National deaths by alcohol abuse | 1 % increase in unemployment increases suicide at 0.79 % in ages younger than 65 years (95 % CI 0 · 16–1 · 42; 60–550 potential excess deaths [mean 310]). A more than 3 % increase in unemployment increases suicide in 4.45 % at ages younger than 65 years (95 % CI 0 · 65–8 · 24; 250–3220 potential excess deaths [mean 1740]) and 28 % deaths from alcohol (12 · 30–43 · 70; 1550–5490 potential excess deaths [mean 3500] | Large cross-national sample covering a period of 37 years. | It is limited to 2007. Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[64] | Cross-national samples of 23 EU countries | Ecological study | 2000–2010 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | A 1 % increase in unemployment rates, suicide rates increase by 34.1 %. | Cross-national level trends analysis covering the period of recession. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. The time series is limited to a decade. |
[65] | Cross-national samples of 20 EU countries | Ecological study | 1981–2011 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National male suicide rates | Male suicide increases significantly 0.94 % with each rise in male unemployment (95 % CI: 0.51–1.36 %) | Large cross-national sample covering a period of 30 years. | Focus only in male suicide. Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[66] | Cross-national samples of 8 EU countries | Ecological study | 2000–2010 | Macroeconomic indicators Unemployment rate and GDP | Suicidal Behaviours National suicide rates | Rise on unemployment rates and decline GDP incresed suicide mortality (Germany +5.3 %, Portugal +5.2 %, Czech Republic +7.6 %, Slovakia +22.7 % and Poland +19.3 %). In low social spending countries, unemployment rate has a stronger effect on suicide. | Cross-national level trends analysis covering the period of recession. | The time series is limited to a decade. The ecological design does not allow for control of potential confounders or effect modifiers. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[67] | National Population sample, USA | Ecological study | 1979–2004 | Macroeconomic indicators Unemployment rate and GDP | Suicidal Behaviours National suicide rates | Higher unemployment rates for prime working-age (35–64) men and women are positively correlated with their higher suicide rates | Cross-state level trends analysis | The time series is limited to 2004, higher effects are expected afterwards. The ecological design does not allow for control of potential confounders or effect modifiers. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[68] | National Population sample, USA | Ecological study | 1997–2010 | Macroeconomic indicators Employment Rate | Suicidal Behaviours National Suicide Rates | Strong positive association between unemployment rates and total suicide rates over time. Strong explanation among the middle-aged suicides but cannot explain temporal variation in suicide rates among the young and elderly. | Examined trends in the total suicide rate and in the rate disaggregated by sex, age group and time period and include a number of important confounding factors in a multivariate analysis. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[69] | National population sample, USA | Ecological study | 1968–2008 | Macroeconomic indicators State level unemployment rate | Suicidal Behaviours State level suicide rates | A 1-percentage-point increase in the state unemployment rate was associated with 0.16 (95 % CI: 0.08, 0.24) more suicide deaths per 100,000 population. The presence of generous state unemployment benefit programs buffer the impact of unemployment rates on suicide. | State fixed-effect analysis covering 1968–2008 on suicide rates | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[70] | National population sample, South Korea | Ecological study | 2003–2011 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | National unemployment rate was positively and significantly associated with the unemployed and employed suicide rate. | National level trends analysis covering the period of recession. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. The time series is limited to 8 years. |
[71] | National population sample, Greece | Ecological study | 1968–2011 | Macroeconomic indicators National unemployment rate, government expenditure | Suicidal Behaviours National suicide rates | Unemployment rates and suicide rates were highly correlated (0.45). 1 % increase in unemployment of males (25–44y), increases suicide rates in 4.5 %. Austerity measures and negative economic growth also significantly increase male suicide rates. | Evaluates specific effects of fiscal austerity, among other socio-economic variables, on suicide rates over recession period. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[72] | National population sample, Greece | Ecological study | 1991–2011 | Macroeconomic indicators Unemployment rate and GDP | Suicidal Behaviours National suicide rates | Suicide rates are positively and significantly correlated with percentage of public debt in GDP and unemployment. | National level trends analysis covering the period of recession and macroeconomic fluctuations | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. The time series is limited to 10 years |
[73] | National population sample, Greece | Ecological study | 2000–2010 | Macroeconomic indicators National unemployment rate, growth rate | Suicidal Behaviours National suicide rates | The correlations between suicidal rates and unemployment and growth rate were about zero. Found no increase in suicidality in Greece during the recession and no relationship of suicidal rates with unemployment rates or growth rate. | Evaluates specific effects of unemployment and growth rates, on suicide rates over recession period. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. The time series is limited to a decade. |
[74] | National population sample, England, UK | Ecological study | 1993–2010 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | The associations between unemployment rate and suicide rates were only statistically significant associations at regional level between 2008 and 2010. | National and regional level trends analysis covering the period of recession. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[75] | National population sample, Hungary | Ecological study | 2000–2011 | Macroeconomic indicators National unemployment rate | Suicidal Behaviours National suicide rates | Unemployment rates might be associated with suicidality in the general population after 3–5 years after the onset of recession (strong positive correlation at 5 years for the general population (0.78)) | National level trends analysis covering the period of recession and suggesting that there is a time lag in the increase of suicide rates. | The time series is limited to a decade Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
[76] | National population sample, USA | Ecological study | 2005–2010 | Macroeconomic indicators State level foreclosure rate | Suicidal Behaviours State level suicide rates | The foreclosure crisis has likely contributed to increased suicides (b = 0.04; P < .1). the effects were strongest among the middle-aged people (46–64 years: total foreclosure rate, b = 0.21; P < .001) | State-level analysis covering 2005–2010 on suicide state rates. | Because of its ecological nature, the quality of data is not assessable and no implications on causality can be drawn. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. The time series is limited to 5 years |
[77] | National population sample, Italy | Ecological study | 2000–2010 | Macroeconomic indicators GDP per person | Suicidal Behaviours National suicide rates | The real GDP was associated with the percentage of male completed suicides due to financial problems b = 0.16, p = 0.05). | National level trends analysis covering the period of recession | Only male suicides were considered. The time series is limited to a decade. The ecological design does not allow for control of potential confounders or effect modifiers. Results should be interpreted with caution as other variables, independent of economic conditions, may be involved in the precipitation of suicide. |
Individual-level indicators associated with mental health outcomes
Unemployment
Study | Setting | Study design | N Year Age | Socioeconomic determinants | Mental health outcomes | Associations/Effects | Strengths | Limitations |
---|---|---|---|---|---|---|---|---|
[78] | National population sample, USA | Cohort | 1510 (1986–2002) >25 y | Individual-level indicators Employment status Socioeconomic status | Psychological Well-being Depressive symptoms (CES-D) | Job loss is linked with follow-up depressive symptoms and, occupational prestige significantly heightened this vulnerability. Unemployment status is significantly associated with depressive symptoms (r: 0.333, S.E.: 0.108) | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Difficult to distinguish truly involuntary job losses from health-related separations. Did not account for life course effects, the role of neighbourhood, or other such effects by which inequality may shape health. |
[79] | National population sample, Australia | Cohort | 7176 2001 20–55 y | Individual-level indicators Employment status | Psychological Well-being Mental health distress (MHI-5) | Negative correlation (r = −0.16) between unemployment and mental health across waves. Mental health is both a consequence of and risk factor for unemployment. | Uses a continuous measure of mental health symptoms. It simultaneously investigates the bi-directional effects of unemployment and mental health. | The analyses was restricted to working age population (20 to 55 years at baseline). The results and recommendations should not be generalized to other cohorts. |
[80] | National population sample, Britain, UK | Cohort | 14,686 (1991–2000) ≥16 y | Individual-level indicators Employment status Financial situation | Psychological Well-being Mental health distress caseness (GHQ-12) | Job loss increased risk of distress for men (OR = 3.15; 95 % CI:2.50–3.98) and women (OR = 2.60; 95 % CI:1.97–3.43). Moving to paid work reduced risk of distress for men (OR = 0.52;95 % CI: 0.41–0.68) and for women (OR = 0.68;95 % CI: 0.69–1.40). Worse off unemployed men are more distressed (OR = 4.19; 95 % CI:3.20–5.50). | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Although, subjective financial difficulty was associated with psychological distress, whether it is causal or the consequence of negative affectivity is not clear. |
[81] | National population sample, New Zealand | Cohort | 15,095 (2004–2009) 15–60y | Individual-level indicators Employment Status Deprivation | Psychological Well-being Mental health distress (Kessler-10 and SF-36) | Job loss decreased MH (SF-36) in 1.34 points (95 % CI −1.85 to −0.82) and increased mental distress in 0.50 points (95 % CI 0.34 to 0.67). Deprivation was associated with a 1.47 (95 % CI −1.67 to −1.28) decline in MH and a 0.57 unit (95 % CI 0.51 to 0.63) increase in mental distress. | Large sample over 5 years. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Those with poor mental health are more likely to subsequently become unemployed or experience more deprivation, so reverse causation might be possible. |
[82] | National population sample, Britain, UK | Cohort | 10,300 16–64y (1991–2009) | Individual-level indicators Employment Status | Psychological Well-being Mental health distress (GHQ-12) | Moving from unemployment to employment was strongly associated with an improvement in mental health −2.1 [95 % CI −2.4 to −1.7], whereas becoming unemployed was detrimental 2.5 (95 % CI 2.2–2.7). | Annual data collected over a 19-year period. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Possible bias due to selection effects threat causal inference since those with poor mental health are more likely to subsequently become unemployed. |
[83] | National population sample, Britain, UK | Cohort | 10,264 16–65y (1991–2007) | Individual-level indicators Employment Status | Psychological Well-being Mental health distress (GHQ-12) | Job loss significantly predicted poorer psychological well-being in comparison to those still employed (2.21; 95 %; CI: 1.99–2.43). | Annual data collected over a 16-year period. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Possible bias due to selection effects threat causal inference since those with poor mental health are more likely to subsequently become unemployed. |
[84] | National population sample, Japan | Cohort | 4800 (2007–2011) 20–40y | Individual-level indicators Employment Status | Psychological Well-being Mental health distress (MHI-5) | Job loss decreases mental health by 12.0 points (MHI-5) after controlling for other variables. | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Direction of causality even after controlling for individual heterogeneity, is difficult to distinguish. |
[85] | National population sample, Australia | Cohort | 5846 2007 > 15 y | Individual-level indicators Employment status Unemployment duration | Psychological Well-being Mental health distress (MHI-5) | Baseline mental health status predicts overall time spent unemployed. 19.1 % of those with poor mental health experience subsequent unemployment compared with 14.6 % of those with better mental health. | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal link. | The analysis was restricted to respondents aging 20–50 years at baseline. The results and recommendations should not be generalized to other cohorts. |
[86] | National population sample, Australia | Cohort | 21,280 (2001–2010) ≥16 y | Individual-level indicators Employment status Number of unemployment spells | Psychological Well-being Mental well-being (SF-36) | Compared to employed people, unemployed people show a 1.64 decrease (95 % CI −2.05 to −1.23, p < 0.001) in mental health, and those who had two or more spells of unemployment show a 2.56 decrease (95 % CI −3.93 to −1.19, p < 0.001). | Large sample. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Lack of data on voluntarily or involuntary job loss (due to illness) self-reported nature of the data on mental health. |
[87] | National population, Sweden | Cross-sectional | 20,538 (2008) 18–85 y | Individual-level indicators Employment status | Psychological Well-being Mental health distress (GHQ-12) psychosomatic symptoms | Unemployed people had reduced psychological well-being (OR = 2.11; 95 % CI: 1.79–2.50) and more psychosomatic symptoms (OR = 1.62; 95 % CI: 1.37–1.92) compared with individuals who were employed. | Large sample. The postal survey reduces the potential bias introduced by interviewer and respondents may answer sensitive questions more honestly. | Its cross-sectional design removes the possibility of causal inference. Postal questionnaire surveys increase non-response sample bias. |
[88] | Community sample, Scania, Sweden | Cross-sectional | 5180 18–64 y | Individual-level indicators Employment status Psychosocial job quality | Psychological Well-being Mental health distress (GHQ-12) | People facing job strain (OR = 3.01; 95 % CI:2.26–4.02) and unemployment (OR = 5.81; 95 % CI:4.33–7.79) have significantly higher odds ratios of psychological distress. | The postal survey reduces the potential bias introduced by interviewer and respondents may answer sensitive questions more honestly. | Its cross-sectional design removes the possibility of causal inference. Postal questionnaire surveys increase non-response sample bias. |
[89] | Regional sample, North West of England, UK | Cross-sectional | 15,228 (2009) | Individual-level indicators Employment status Deprivation | Psychological Well-being Life satisfaction Mental well-being | Deprivation strongly linked to low LS and MWB. 17.1 % of the most deprived tertile have low LS compared to 8.9 % in the most affluent. | It identifies the characteristics of individuals most likely to suffer from poor Well-being | Its cross-sectional design removes the possibility of causal inference. |
[90] | National population sample, Brazil | Cross-sectional | 5000 (2003) >18 y | Individual-level indicators Employment status | Common Mental Disorders State of animus (World Health Survey) | Among women, level of education and unemployment were associated to feelings of depression and anxiety. Among males, feelings of depression were strongly associated with unemployment. | This study provides data on the negative effects of unemployment on depression and anxiety, which are important predictors of subsequent morbidity. | Its cross-sectional design removes the possibility of causal inference. Generalizing findings may be reasonably limited to the uniqueness of the Brazilian welfare system. |
[91] | Cross-national samples of older adults from 13 EU countries and USA | Cohort | 15,055 (2006–2010) 50–64 y | Individual-level indicators Employment status | Common Mental Disorders Depressive symptoms (EURO-D and CESD) | Unemployment was associated with 4.78 % [95 % (CI): 0.823 to 8.74 %] increase in depressive symptoms in the USA and 3.35 % (95 % CI: 0.486 to 6.22 %) increase in Europe. | Bias due to selection and reverse causality was lessen because the study distinguished job loss due to plant closures, and used individual fixed effect models. | Used two measures for depressive symptoms Euro-D for Europe and CESD for USA. However, these were normalized. The analysis was restricted to older adults (50–64y). |
[92] | Cross-national sample of primary care patients from EU and Chile | Cohort | 10,059 (2003–2004) 18–75 y | Individual-level indicators Employment status | Common Mental Disorders Depression caseness Composite International Diagnostic Interview (CIDI) | Job loss between baseline and 6 months compared to those employed at both times had an adj relative risk ratio for 12-month depression of 1.58 (95 % CI:0.76, 3.27). Participants with depression at baseline and 6 months compared to neither time had an OR for 6-month unemployment of 1.58 (95 % CI:0.97, 2.58). | It examines the interrelations between unemployment and clinical depression in both directions across different countries producing stronger causal conclusions. | No available data on whether employment is full time or part-time or underemployment. If unemployed adults with depression are less likely to seek medical treatment they may be under-represented in the GP-based sampling frame. |
[95] | Cross-national samples of European Countries | Cross-sectional | 34,395 (2001–2009) > 18 y | Individual-level indicators Employment status Education level Income and Occupation | Common Mental Disorders Anxiety Mood disorder | Unemployed showed the highest prevalence and increased risk of 12-month mental disorders. Mood disorders and anxiety were more prevalent among those receiving a low and a low-average income Northern Ireland, Portugal and Belgium were the countries with the highest risk for mental disorders. | This study examines the associations between employment status and mental health in a European representative sample. Specifies which countries are at higher risk for mental disorders. | Since data derives from different countries during a wide time interval (2001–2009) to determine the impact of the adverse economic conditions of the past few years was not possible. Participants from different countries have been exposed to different economic scenarios and the study was unable to evaluate the impact of this. No causal inference can be made due to the cross-sectional nature of the study |
[93] | National population sample, England, UK | Cross-sectional | 5090 ≥16 y | Individual-level indicators Employment status | Common Mental Disorders CIS-R interview: Common Mental Disorders (CMD) | Risk of CMD was significantly greater in unemployed individuals; economically inactive; not working due to physical health reasons; unable to find a suitable job among others. Individuals unemployed for less than 1 year or more than 3 years had a higher risk of CMD. | Uses a well validated scale for detection of common mental disorders. | Its cross-sectional design removes the possibility of causal inference. |
[94] | National population sample, Sweden | Cross-sectional | 42,448 (2004) 18–84 y | Individual-level indicators Employment status Financial strain | Common Mental Disorders Anxiety Depression (EQ-5D) | Unemployment (OR = 2.9; 95 %; CI:2.2–4.0), economic hardship (OR = 3.1; 95 %; CI:2.4–3.9 were strongly and independently related with anxiety/depression. | Large and population-based study that uses an internationally validated scale of quality of life that measures anxiety and depression. | No causal inference can be made due to the cross-sectional nature of the study. |
[96] | National population of employees of collapsed major banks, Iceland | Cross-sectional | 1880 (2009) >20 y | Individual-level indicators Employment status (Downsizing) | Common Mental Disorders Depression and anxiety symptoms (AOSH) | Downsizing, salary cut, and transfer to another department is associated with increased psychological distress | Nationwide sample and the inclusion of all employees of collapsed major banks in one country highly hit by the economic recession | No causal inference can be made due to the cross-sectional design and self-reported data. This sample was drawn from the collapse of banks in Iceland, so generalizing findings to other countires may be limited |
[97] | National population sample, Finland | Case–control | 5859 cases 74,809 controls | Individual-level indicators Employment status Socioeconomic status | Substance-Disorders Driving under the influence of drugs (DUID) | Low education, unemployment, disability pension, being divorced and living alone were the strongest individual predictors of DUID in all substance groups. | Large sample size, based on two registers ensuring good coverage and validity, increases reliability of the study. It shows that disadvantaged social background is related to driving under the influence of drugs. | Impaired drivers were over-represented: the cases were suspected and apprehended of DUID by the police. Not all people driving under the influence are caught (fewer than 10 %). The direction of causality remains unclear. |
[98] | National population sample, USA | Repeated Cross-sectional | 405,000 (2002–2010) >18y | Individual-level indicators Employment status | Substance-Disorders alcohol use/abuse/dependence; illicit drug use/abuse/dependence and tobacco use | Unemployed people show higher prevalence of alcohol use, illicit drug use, tobacco use, alcohol abuse or dependence, and illicit drug abuse or dependence then employed. This was before, at the start of, and during the 2009–2010 period of high unemployment. | Nationally representative sample of US adults. Strong association between substance disorders and unemployment. | Cross-sectional data does not allow tests of causality among the reported associations. Possible bias due to validity of self-reports of sensitive behaviours |
[99] | National population sample, USA | Cross-sectional | 5307 (2009–2010) >18y | Individual-level indicators Employment status housing payment problems | Substance-Disorders Alcohol Dependence Negative drinking consequences | Housing payment instability was associated with experiencing more negative drinking consequences and alcohol dependence symptoms. Job loss was strongly associated with alcohol problems in univariate models, but no significant associations were observed in multivariate models. | Nationally representative sample of US adults. Strong association between alcohol drinking patterns and housing instability and unemployment. | Does not preclude the possibility of reverse causation (individuals with existing alcohol problems prior to the study) |
[100] | Community sample of job-seekers, Germany | Cross-sectional | 7906 (2008–09) 18–64 y | Individual-level indicators Employment status Duration of unemployment | Substance-Disorders Smoking, risky drinking, illicit drug use. Self-rated health | 52.4 % of the sample (53.4 % male, 33.5 years mean age) had 3 or more health risk factors. 84.8 % of the 18–24 year old long-term unemployed men were smokers. Substance use risk factors were highest among the 18–24 year olds All health risk factors were associated with lower self-rated health. | Very high proportions of individuals with health risk behaviours were found, and associations with self-rated health were confirmed in a sample of job-seeker individuals. | No causal inference can be made due to the cross-sectional design. The validity of self-reports of sensitive behaviours, such as alcohol consumption. Since the research focused job-seekers the sample included both unemployed and employed individuals. This sample was drawn from one area in Germany so generalizing findings may be limited |
[101] | National population sample, South Korea | Ecological Study | 1995–2005 | Individual-level indicators Employment status | Substance-Disorders Alcohol-attributable mortality | Found an incidence of 20 times higher alcohol-attributable deaths rate of unemployed compared to those of non-manual workers during recession | Brings national evidence on the inequalities in the health effects of economic changes. | Did not consider accidental deaths caused directly by alcohol (eg falls). The real magnitude of social disparity in alcohol-attributable death rates may be even greater than that estimated. Social disparity in alcohol-attributable mortality cannot be said to be a result of the crisis because this was tested. |
[102] | Community sample, emergency departments in Edmonton, Canada | Case–control | 507 cases 200 controls (1993–94) >16 y | Individual-level indicators Employment status | Suicidal Behaviours Parasuicide | There is an association between unemployment and parasuicide (OR = 12.0; 95 % CI:6.0–23.9) | Brings strong evidence on the influence of exposure to unemployment on parasuicidal behaviour in comparison to a control group. | There is low response rate for both cases and controls. |
[103] | Cross-national samples from 21 countries worldwide | Cross-sectional | 108,705 (2001–07) >18y | Individual-level indicators Employment status Educational level | Suicidal Behaviours Suicidal ideation and attempts (CIDI) | 12-month prevalence of suicide ideation, plans and attempts are 2.0, 0.6 and 0.3 % respectively for developed countries and 2.1, 0.7 and 0.4 % for developing countries. Risk factors for suicidal behaviours in both developed and developing countries included being a woman, low educated, low income, and being unemployed (among others). | Large cross-national epidemiological survey database | No causal inference can be made due to the cross-sectional nature of the study. Reported suicidal ideation and suicide attempts can be susceptible to recall bias or to reluctance on the part of respondents to disclose such a sensitive information. |
[104] | National population sample, Australia | Cross-sectional | 4697 (2007–2009) 15–64 y | Individual-level indicators Employment status | Suicidal Behaviours Death by Suicide | During 2001–10 economically inactive/unemployed males suicide at 4.62 times (RR = 4.62; 95 % CI: 4.10, 5.19; P < 0.001) the rate of employed men (RR = 1.00). Economically inactive/unemployed females had a suicide RR of 8.44 compared with employed females (95 % CI 7.38, 9.67; P < 0.001). | Best available national data and provides information on the employment status of individual suicide cases. | Possible under-reporting of suicide data and under-report of the long-term unemployed that have given up looking for work (i.e. discouraged job seekers). Lack of available data on confounding factors. |
[105] | National population sample, Spain | Cross-sectional | 4583 (2001–2002) >18y | Individual-level indicators Employment status | Suicidal Behaviours Suicidal ideation and attempts (CIDI) | Being unemployed or having work disability were also associated with suicidal ideation in people aged 18–49. The prevalence of suicidal ideation and attempts found in this study is similar to the one found ten years ago, before the economic crisis | Representative sample of the national population in Spain during the economic recession. The data was collected in the same way as in the ESEMED study, making it possible to compare current figures with the prevalence found before the crisis. | No causal inference can be made due to the cross-sectional nature of the study. Reported suicidal ideation and suicide attempts can be susceptible to recall bias or to reluctance on the part of respondents to disclose such a sensitive information. |
Precarious and insecure work
Study | Setting | Study design | N Year Age | Socioeconomic determinants | Mental health outcomes | Associations/Effects | Strengths | Limitations |
---|---|---|---|---|---|---|---|---|
[106] | National population sample, Finland | Cohort | 3449 31 y | Individual-level indicators Psychosocial job quality and Security | Psychological Well-being Mental health distress caseness (HSCL-25) Self-reports of GP | The precarious workers have more distress symptoms in comparison with permanent workers. No differences in doctor-diagnosed/treated illnesses between precarious and permanent workers. | It measures mental health and correlates with self-reports of doctor diagnosed/treated illnesses. Temporal order of exposures and confounders affected all participants at the same time producing stronger causal conclusions. | Cannot make differential analysis of health-based selection. The results and recommendations should not be generalized to other cohorts. |
[107] | Regional population sample, Northern Sweden | Cohort | 1071 30–42y | Individual-level indicators Psychosocial job security | Psychological Well-being Self-rated health, sleep quality and mental health | The adverse effects of job insecurity on health are present on both permanent and temporary employees. | The study has a follow-up design. Temporal order of exposures affected all participants at the same time producing stronger causal conclusions. | The results and recommendations should not be generalized to other cohorts. |
[108] | Community sample of workers from private organization, Italy | Cross-sectional | 1236 (2010–2011) | Individual-level indicators Psychosocial job quality and Security | Psychological Well-being Mental health distress (GHQ12) | Job stress fully mediated the relationship between fear of the crisis and mental health of the workers. | Large sample and uses a well validated scale for detection of mental distress. | Its cross-sectional design removes the possibility of causal inference. Possible response bias since those with mental distress may perceive and rate the same work environment more stressful than those without mental distress. |
[109] | National Population sample, England, UK | Cross-sectional | 2603 20–55 y | Individual-level indicators Employment Status Psychosocial job quality | Common Mental Disorders CIS-R interview: Common Mental Disorders (CMD) | The prevalence of mental disorders among unemployed (33.1 %) was greater than in employed (12.9 %; OR 3.34, 95 % CI 2.06–5.42, p < 0.001). Results were similar for those respondents in the poorest quality jobs. | Uses a well validated scale for detection of common mental disorders. | Its cross-sectional design removes the possibility of causal inference. Possible response bias since those with mental illnesses may perceive and rate the same work environment more negatively than those without a disorder. |
[110] | National working population sample, UK | Cross-sectional | 3581 (2007) 16–64y | Individual-level indicators Psychosocial job security Indebtedness | Common Mental Disorders Depression | Risk of depression is greater for poor job security (OR = 1.58, 95 %; CI:1.22–2.06). Adj for age and sex, job insecurity (OR = 1.86, 95 % CI:1.47–2.35) and debt (OR = 2.17, 95 % CI:1.58–2.98) were independently associated. | Large representative sample. | Its cross-sectional design removes the possibility of causal inference: job insecurity may be more frequently reported by people rendered pessimistic by a mood disorder. |
[111] | National population sample, USA | Cohort | 34,653 (2001–02; 04–05) ≥20 y | Individual-level indicators Household income Socioeconomic inequalities | Common Mental Disorders Substance use disorders (AUDADIS-IV) | A decrease in household income during the 2 time points was associated with an increased risk of incident mood, anxiety, or substance use disorders (adj OR = 1.30; 99 % CI:1.06–1.60) | Nationally representative sample and strong associations. Temporal order of exposures produces stronger causal conclusions. | Unable to adjust for physical health conditions that may be potential confounders. |
[112] | National population sample, New Zealand | Cohort | 15,340 (2002–2004/05) >25 y | Individual-level indicators Total wealth Socioeconomic inequalities | Psychological Well-being Mental health distress (Kessler-10) | High psychological distress linked to lowest wealth quintile compared with the highest (OR 3.06, 95 % CI 2.68 to 3.50). Adj for age and sex did not alter the relationship; adj for income and area deprivation attenuated the OR to 1.73 (95 % CI 1.48 to 2.04); adj baseline health status reduced the OR to 1.45 (95 % CI 1.23 to 1.71). | Strong associations between inequalities in wealth and psychological distress. Temporal order of exposures and confounders affected all participants at the same time producing stronger causal conclusions. | The socioeconomic position at baseline was not controlled. The results and recommendations should not be generalized to other cohorts. |
[113] | National population sample, Britain, UK | Cohort | 8185 (1991) (2003) | Individual-level indicators Indebtedness housing payment problems | Psychological Well-being Mental health distress caseness (GHQ-12) | Housing payment problems and debts have significant detrimental effects on mental Well-being. The sizes of these effects are in addition to and larger in magnitude than those associated with financial hardship. | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | Generalizing findings may be reasonably limited to the UK’s welfare system in regard to housing payment problems. The results and recommendations should not be generalized to other cohorts. |
[114] | Community sample, Detroit, USA | Cohort | 1547 (2008) (2010) | Individual-level indicators Home foreclosure Financial hardship | Common Mental Disorders Major depression (PHQ-9) Generalized anxiety disorder (GAD-7) | Foreclosure was associated with an increased rate of major depression [incidence density ratio (IDR) 2.4, 95 %; CI:1.6–3.6] and GAD (IDR 1.9, 95 %; CI:1.4–2.6) | Establishes longitudinal associations between home foreclosure and common mental disorders producing stronger causal conclusions. | The sample is limited to a longitudinal cohort of pre-dominantly African-American adults. Because mental health problems are common among individuals at risk of foreclosure, the observed associations may result, in part, from pre-existing psychopathology. |
[115] | Community sample, Wales, UK | Cross-sectional | 88,623 (2003/04–2010) 18–74 y | Individual-level indicators Area income deprivation Socioeconomic inequalities | Psychological Well-being Mental health distress (MHI-5) | High neighbourhood income inequality was associated with better mental health in low-deprivation neighbourhoods (P = 0.036). Income inequality at regional level was significantly associated with poorer mental health (P = 0.012). | Uses a continuous measure of mental health symptoms. Large sampling fraction. | No data were available on individual income. Its cross-sectional design removes the possibility of causal inference. |
[116] | Community sample, France | Cohort | 1103 (1991–2009) 22–35 y | Individual-level indicators Socioeconomic status Level of education | Substance-Disorders tobacco, cannabis use, other illegal drug use | Low socioeconomic status was linked with higher rates of tobacco smoking [OR = 2.11, 95 % CI 1.51–2.96], cannabis use [OR = 1.75, 95 % 1.20–2.55], problematic cannabis use [OR = 2.44, 95 % CI 1.38–4.30] and other illegal drugs [OR = 2.27, 95 % CI 1.11–4.65]. | Relatively large community sample of young adults. Longitudinal measures of family and juvenile characteristics obtained independently of participants’ reports of substance-use | The research focused only young adults whose parents worked in a large national company and were part of an ongoing epidemiological study. Other variables that can act as confounders were not controlled: family and peer characteristics. |
[117] | National population sample, England, UK | Cross-sectional | 7461 (2007) 35–54 y | Individual-level indicators Indebtedness | Suicidal Behaviours Suicidal ideation | Those in debt were twice as likely to think about suicide after controlling for socio-demographic, economic and lifestyle factors. | Representative sample. Strong association between suicidal thoughts and being in debt. | No causal inference can be made due to the cross-sectional nature of the study. |
Debt, deprivation, and financial hardship
Families, children, and older people
Study | Setting | Study design | N Year Age | Socioeconomic determinants | Mental health outcomes | Associations/Effects | Strengths | Limitations |
---|---|---|---|---|---|---|---|---|
[118] | Regional sample of parents and children, Southern Finland | Cohort | 1149 12 y 843 mothers 30–59y 573 fathers 28–66 y | Individual-level indicators Family perceived financial strain | Psychological Well-being Parental Mental health distress caseness (GHQ-12) Child mental health | Family economic hardship creates a risk for child mental health through economic pressures and problems in parental mental health, marital interaction, and parenting even in a welfare state. | Gives information on transgenerational effect of family economic pressure on child mental health. Child mental health was reported by both parents and children, which adds to the reliability. Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions | Reporter bias is expected since mothers and fathers reported on their own mental health and parenting. Other contexts determinants such as reductions in funding in day care and schools can act as confounders. Generalizing findings is limited to the uniqueness of the Finish welfare system with extensive governmental support to families. |
[119] | Cross-national samples of adolescents, 31 countries worldwide | Repeated cross-sectional | 164,623 (2005–2006) 168,284 (2009–2010) 11–15y | Inter-time Variables Macroeconomic indicators Unemployment Rates | Psychological Well-being Psychological health complaints (HBSC symptom checklist) | Ireland and Portugal were the only countries facing a rise In psychological health complaints (9–17 %) with increasing unemployment (21–148 %). Youth unemployment rates in 2010 increased the likelihood of psychological health complaints. | Uses nationally representative data on adolescents from 31 countries, surveyed over two time points, before and after recession | Data derives from 2006–2010 and the crisis started in 2008 so the long term effects of the recession could not be investigated. The sample is composed only by adolescents aging 11 to 15 years old. |
[120] | National population sample of adolescent, Slovenia | Cross-sectional | 1815 (2010) 15y | Individual-level indicators Family Affluence Scale, perceived material welfare, family type, occupational status of parents | Psychological Well-being Mental health (KIDSCREEN-10, SDQ), Life satisfaction Feelings of depression | The adolescents who perceived to be socioeconomically worse off had 4-times higher odds (p < 0.001) of a low life satisfaction, a greater chance of a low quality of life, and a higher SDQ score than those who perceived to be better off (p < 0.001). | Uses a national representative sample and several variables to measure socioeconomic status. | Includes only 15-year-olds who are enrolled in school and does not include dropouts, who might be among the most socioeconomically underprivileged. Its cross-sectional design removes the possibility of causal inference. |
[121] | National population sample of adolescents, Portugal | Cross-sectional | 4877 (2010) 10–18 y | Individual-level indicators Parental employment status | Psychological Well-being Health Related Quality of Life | Having at least one parent unemployed has a statistical significant negative impact on perceptions of adolescent health. | Gives important information about the transgenerational effect of employment status. | Its cross-sectional design removes the possibility of causal inference. The study was not designed specifically to address causal links between the variables and parental employment. |
[122] | Cross-national samples of children and adolescents, Denmark and Sweden | Cross-sectional | 4299 2–17 y (1996) | Individual-level indicators Parental employment status | Psychological Well-being Psychosomatic symptoms | Children in families with one or both parents without paid work had an increased prevalence of recurrent psychosomatic symptoms (OR = 1.52 to 3.20) | Gives important information about the transgenerational effect of employment status. | Underreporting bias is expected as children differ in their tendency to report symptoms to their parents. Also the parents’ reports on their children can depend on their own health. Its cross-sectional design removes the possibility of causal inference. |
[123] | Regional sample of adolescents, Kosice, Slovakia | Cross-sectional | 2836 14–22 | Individual-level indicators Parental employment status | Psychological Well-being Self-rated health Long-term well-being Health complaints | Parental long-term unemployment (especially of fathers) is negatively associated with adolescents’ subjective health. Father’s long-term unemployment was a significant predictor of moderate self-rated health and low long-term well-being among girls and boys. Mother’s long-term unemployment was negatively associated with self-rated health of girlss and long-standing illness among boys. | Gives important information about the transgenerational effect of employment status. | Lack of specific detailed information about parental unemployment (maternity leave of mothers, retirement, or invalidity of parents were considered unemployment) |
[124] | Regional sample of adolescents, emergency room, Ontario, Canada | Cohort | 15,739 (2002–2011) 12–17 y | Inter-time Variables Pre and Post- recession period | Suicidal behaviours Hospital records of suicide-related behaviours | The suicide-related behaviours incidence rates decreased by 30 % in boys and girls from FYs 2002/03 to 2006/07, but stopped afterwards and subsequent admissions increased. | Large sample of adolescents and examines trends in the total suicide related behaviour during recession periods. | The hospital records do not identify suicidal intent. Data is not representative of the general population. Suicide-related behaviours are complex and other variables may act as confounders. |
[125] | National population sample of adolescent, USA | Repeated cross-sectional | 403,457 (1997–2009) mean age 16 y | Macroeconomic indicators State level job loss | Suicidal Behaviours Suicide ideation, attempts and plans | State level unemployment during the year preceding the survey increased girls’ probability of suicidal ideation and suicide plans, but did not affect the suicide-related behaviors of boys | Uses a national representative sample and Gives important information about economic circumstances effects on adolescents risk behaviours. | It is unable to identify the pathways through which unemployment rates affect adolescents’ suicide-related behaviors. |
[126] | Regional sample of older adults, Canberra/Queanbeyan, Australia | Cohort | 1973 (2005–2010) mean age 66.58 y (SD = 1.5) | Inter-time Variables Individual-level indicators Pre and Post- recession period Financial security Financial hardship | Common Mental Disorders Depression Anxiety (Goldberg Scales) Self-reported health | Economic slowdown related distress is linked to greater depression symptoms at both waves 2 (t(655) = −3.44,p = .001) and 3 (t(662) = −4.96, p < .001), and greater anxiety symptoms at both waves (wave 2 - t(655) = −3.62, p < .001; wave 3 - t(662) = −5.15, p < .001). | Temporal order of exposures, confounders, and the outcome under consideration affected all participants at the same time producing stronger causal conclusions. | The analysis was restricted to older adults at baseline. Consequently, the results and recommendations should not be applied to younger cohorts. Limited period of time, the long term effects of the recession could not be investigated. |
[127] | National population sample of older adults, USA | Cohort | 2261 (2005–2006) (2010–2011) >57 y | Individual-level indicators Home foreclosure | Common Mental Disorders Depressive symptoms (CES-D) | Increases in neighborhood-level foreclosure was associated with an increased rate in depression in older adults. Notices of default (OR = 1.75; 95 % CI = 1.14, 2.67) and properties returning to ownership by the bank (OR = 1.62; 95 % CI = 1.06, 2.47) were associated with depressive symptoms. | Establishes longitudinal associations between home foreclosure and depressive symptoms producing stronger causal conclusions. | The mechanisms linking increases in foreclosure to depressive symptoms are not explored. The sample is limited to a longitudinal cohort of older American adults. |
[128] | Cross-national working population sample, European Union countries | Cross-sectional | 20,368 (2006) 20,124 (2010) 18–64 y | Inter-time Variables Macroeconomic indicators ndividual-level indicators Pre and Post- recession period Employment Status Sate level unemployment | Psychological Well-being Mental health distress (MHI-5) Mental health disorders | Following the onset of the recession, individuals with mental health problems were more vulnerable to losing their jobs [OR = 1.12, 95 % CI: 1.03–1.34] (OR: 1.12, 95 % CI: 1.03, 1.34). | Uses nationally representative data on people with and without mental health problems from 27 countries in Europe surveyed over two time points, before and after recession. | The data was collected through brief, self-reported questionnaires. Limited period of time, the long term effects of the recession could not be investigated. Its cross-sectional design removes the possibility of causal inference. |
People with mental health problems
Discussion
Research and policy implications
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it is plausible that the actual recession increased the population’s psychological distress;
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according to the evidence reviewed, periods of recession correlate with higher prevalence of common mental disorders, substance disorders, and ultimately suicidal behaviour;
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it may be possible that in order to cope with psychosocial stress people might turn to substance misuse;
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some key factor seem to make people more vulnerable to the effects of the recession: being unemployed, having a precarious work situation, facing debts and economic strain, and having a pre-existing mental illness;
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economic recession may also have a severe and long-term impact on mental health in children and young people, especially if they face stress within the family as a result of economic hardship or parental unemployment;
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some specific differences between countries and regions were found in this review. The authors hypothesise that this may be explained by the socioeconomic response policy to recession (the presence of unemployment benefits or social programmes) which could influence changes in the mental health outcomes of the populations;
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more research is needed concerning mediating factors between the determinants of a recession and mental health outcomes;
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more research from countries badly hit by the economic recession and from low and middle income countries is needed;
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the links between recession and direct effects on health seem to be very complex, and the lagged effects have not been systematically studied because of a lack of longitudinal studies and therefore a scarcity of long data series persists.
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active labour market programmes
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family support programmes
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regulation of the marketing of alcoholic beverages, restrictions on their availability, and taxation
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provision of quality and equitable access to primary care for those people at high risk of mental health problems
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debt relief programmes.