This is all I have left.

My patient, faced with significant financial issues, reached into his pocket and pulled out some change. “Everything else is gone,” he said.

The year was 2010. My patient had spent decades managing a GM dealership but, with widespread company problems, he lost his job and the dealership closed. He described to me walking out one evening with an appointment book filled with future meetings only to realize the next day that he had nothing to do. “I’m an adrenalin junkie.” The long 12-hour work days were replaced by the uncomfortable monotony of unemployment. My patient was lost — and depressed and suicidal.

I remember thinking how stressful those days were, as people saw their fortunes change in the winds of the economic downturn. My patient was not alone in his despair. The connection between economic woes and suicide has long been noted.

The Economist recently asked if Britain was “no country for old men.” Looking at 3 decades worth of data, the magazine reported that there has been a sharp uptick in non-elderly British men who suicided.

Note that the trend seems to apply to men, but not to women.

Recessions are times of great stress — and, yes, higher suicide rates. But how closely is suicide tied to unemployment and what lessons can be learned from this recent recession? The Lancet Psychiatry just published a paper considering these questions and drawing on an impressive dataset. In “Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000–11,” Dr. Carlos Nordt and his colleagues at the University of Zurich consider the last recession.

As they note, much work has been done in this area. When they did a search (using terms like “suicide,” “unemployment,” “economic crisis” and “prevention”), they found many papers. But with a specific focus on the 2008 recession and world regions, they found just one other paper.

The Lancet Psychiatry study isn’t just impressive, it’s important because of its broader implications for public policy.

Here’s what they did:

  • Based on sample size and completeness of the data, Nordt et al.chose 63 countries. They divided these nations into 4 geographic zones.
  • They considered the period from 2000 to 2011, allowing them to look at the economic downturn that started in 2008 and, also, non-recessionary periods.
  • They drew on the WHO mortality database and IMF’s world economic outlook database.
  • They then estimated the number of suicides tied to joblessness.

They found:

  • The relative risk of suicide was associated with unemployment was elevated by 20-30%. (!)
  • Suicide rates increased 6 months after the unemployment rate rose, suggesting a lag time.
  • Men and women seemed to be affected equally (thereby different from the British data noted above), though different regions yielded different results.
  • A rise in unemployment was particularly problematic in areas with lowerunemployment. So an increase of the unemployment rate from, say, 3 to 6% pushed up the suicide rate more than an increase from 12 to 15%.
  • Their final statistical model estimated that approximately 233,000 suicides occurred each year, of which 45,000, or nearly one in five, were related to unemployment. (!!)

There were, of course, limitations to the study, like the fact that the data was small in certain areas (Africa in particular).

Like all good studies, this paper ends up raising more questions than it answers. Why the 6 month lag time? What are the characteristics of those most likely to suicide? Were the elderly really insulated from the devastation of the economic slowdown or was this study just limited in its scope, and the elderly struggled in other ways (like my patient, who never suicided but turned to alcohol and neglected his physical health)?

More importantly, from a public policy perspective, what can we learn?

Certainly, there seems much here to learn in terms of suicide prevention. The authors weigh in on this, and conclude:

This finding means that there is a continuous need to focus on preventing suicides, even more so in economically prosperous, stable time periods than in times of lower prosperity, when sources are scarcer. These efforts are necessary and valuable not only in countries with high, but also in those with low, unemployment rates.

I’m not quite sure that the paper justifies this statement. But whether or not you agree, this much is clear: during times of recession, governments tend to focus on economic remedies (jobs programs, austerity, tax cuts) and don’t pay enough attention to suicide prevention.


Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.