Table 3 Characteristics of studies included in review relating macroeconomic indicators and mental health outcomes, 2004–2014

[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.