Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries
Impact of the 2008 global economic crisis on suicide: Myths and misconceptions
Konstantinos N. Fountoulakis
Associate Professor of Psychiatry, 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece kfount@med.auth.gr
Recently a study on the relationship of the 2008 global economic crisis on suicide has been published by the BMJ [1]. Unfortunately this paper contains a number of inaccuracies and omissions and we wish to comment on them. The most important are as follows:
1. The authors again and again in this publication, as well as in previous ones suggest there is an increase in suicides after 2007 in spite of the fact that for example for Greece during that year there was a random trough in suicide rates followed by the usual rate for 2008-9 [2]. Similar issues have been raised concerning the interpretation of data from other countries [3].
2. In the current as well as in previous publications the authors utilize a linear model which is clearly not appropriate for suicide data, given their very high variability across countries and continents.
3. In spite of the fact that they correlated ‘change in unemployment’ with ‘suicidal rates’ (a very sensitive choice of variables), they failed to detect any significant correlation (p>0.05). Even if significance is not taken into consideration, the coefficients were too small (0.25 for men and 0.10 for women) to deserve discussing them. Still the authors consider this to be a major finding.
4. The authors do not seem to take into consideration the possibility that unemployment might not be a crucial factor concerning suicidality. They mention (but fail to comment) that a 37% rise in unemployment was accompanied by an only 3% fall in GDP during 2009. In a previous publication it has been mentioned that unemployment and suicidality regression lines were identical concerning the US data [4], however they failed to mention that the rise in suicidality preceded for one year that of unemployment [5]. In the current paper it is interesting that they avoid plotting both the suicide rate and unemployment rate vs year in the same plot.
5. The authors report an excess of 4900 suicides in the year 2009 in comparison to their predictive model. However even if one looks closer at the data presented, significant increases in suicidal rates were observed for females only in 19 countries and in 33 for males (out of 54).
6. The hypothesis that the economic crisis is largely responsible for the increase observed in specific countries is in contrast with the reporting of the authors that a large portion of the increase concerns males aged 15-24 and the increase is smoothly distributed through the ages 15-64. It is also in sharp contrast to the recent finding that the increase in female suicides is mainly responsible for the increase in the suicide rate in Greece for the year 2011 [6].
7. In the discussion, concerning Greece, in spite of previous publications with overlapping authors [7-10], the authors of that paper fail to give the acurate picture of suicidality and mental health in Greece today [2 3 6 11 12].
Conclusively, it seems that suicides are increasing in the last few years. The population aged over 15 of the countries included in that study is roughly 1.1 billion people and the increase in suicides corresponds to around 0.44 per 105 residents. Since the average world suicide rate is above 10 and probably around 16 per 105 residents, this change is below 5% and probably non or marginally significant However this should not cover the fact that the trend is rather clear still premature to interpret. The role of the economic crisis and austerity is unclear, mainly because the data fluctuate with a period of decades, they manifest huge variability, peculiar changes in subgroups (e.g. mainly an increase in female suicides in Greece during 2011) and because the temporal correlations are problematic.
References
1. Chang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ 2013;347:f5239 doi: 10.1136/bmj.f5239
bmj.f5239 [pii][published Online First: Epub Date]|.
2. Fountoulakis KN, Grammatikopoulos IA, Koupidis SA, Siamouli M, Theodorakis PN. Health and the financial crisis in Greece. Lancet 2012;379(9820):1001-2; author reply 02 doi: 10.1016/S0140-6736(12)60422-X
S0140-6736(12)60422-X [pii][published Online First: Epub Date]|.
3. Fountoulakis KN, Siamouli M, Grammatikopoulos IA, Koupidis SA, Siapera M, Theodorakis PN. Economic crisis-related increased suicidality in Greece and Italy: a premature overinterpretation. J Epidemiol Community Health 2013;67(4):379-80 doi: 10.1136/jech-2012-201902
jech-2012-201902 [pii][published Online First: Epub Date]|.
4. Reeves A, Stuckler D, McKee M, Gunnell D, Chang SS, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012;380(9856):1813-4 doi: 10.1016/S0140-6736(12)61910-2
S0140-6736(12)61910-2 [pii][published Online First: Epub Date]|.
5. Fountoulakis KN, Koupidis SA, Siamouli M, Grammatikopoulos IA, Theodorakis PN. Suicide, recession, and unemployment. Lancet 2013;381(9868):721-2 doi: 10.1016/S0140-6736(13)60573-5
S0140-6736(13)60573-5 [pii][published Online First: Epub Date]|.
6. Fountoulakis KN, Koupidis SA, Grammatikopoulos IA, Theodorakis PN. First reliable data suggest a possible increase in suicides in Greece. BMJ 2013;347:f4900 doi: 10.1136/bmj.f4900
bmj.f4900 [pii][published Online First: Epub Date]|.
7. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381(9874):1323-31 doi: 10.1016/S0140-6736(13)60102-6
S0140-6736(13)60102-6 [pii][published Online First: Epub Date]|.
8. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Effects of Greek economic crisis on health are real. BMJ 2012;345:e8602; author reply e08 doi: 10.1136/bmj.e8602
bmj.e8602 [pii][published Online First: Epub Date]|.
9. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011;378(9801):1457-8 doi: 10.1016/S0140-6736(11)61556-0
S0140-6736(11)61556-0 [pii][published Online First: Epub Date]|.
10. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet 2011;378(9786):124-5 doi: 10.1016/S0140-6736(11)61079-9
S0140-6736(11)61079-9 [pii][published Online First: Epub Date]|.
11. Fountoulakis KN, Savopoulos C, Siamouli M, et al. Trends in suicidality amid the economic crisis in Greece. Eur Arch Psychiatry Clin Neurosci 2013;263(5):441-4 doi: 10.1007/s00406-012-0385-9[published Online First: Epub Date]|.
12. Fountoulakis KN, Pantoula E, Siamouli M, et al. Development of the Risk Assessment Suicidality Scale (RASS): a population-based study. J Affect Disord 2012;138(3):449-57 doi: 10.1016/j.jad.2011.12.045
S0165-0327(12)00003-1 [pii][published Online First: Epub Date]|.
Rapid Response:
Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries
Impact of the 2008 global economic crisis on suicide: Myths and misconceptions
Konstantinos N. Fountoulakis
Associate Professor of Psychiatry, 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece
kfount@med.auth.gr
Pavlos Theodorakis
WHO National Counterpart for Mental Health, Greece
theodorakispavlos@gmail.com
Dear sir
Recently a study on the relationship of the 2008 global economic crisis on suicide has been published by the BMJ [1]. Unfortunately this paper contains a number of inaccuracies and omissions and we wish to comment on them. The most important are as follows:
1. The authors again and again in this publication, as well as in previous ones suggest there is an increase in suicides after 2007 in spite of the fact that for example for Greece during that year there was a random trough in suicide rates followed by the usual rate for 2008-9 [2]. Similar issues have been raised concerning the interpretation of data from other countries [3].
2. In the current as well as in previous publications the authors utilize a linear model which is clearly not appropriate for suicide data, given their very high variability across countries and continents.
3. In spite of the fact that they correlated ‘change in unemployment’ with ‘suicidal rates’ (a very sensitive choice of variables), they failed to detect any significant correlation (p>0.05). Even if significance is not taken into consideration, the coefficients were too small (0.25 for men and 0.10 for women) to deserve discussing them. Still the authors consider this to be a major finding.
4. The authors do not seem to take into consideration the possibility that unemployment might not be a crucial factor concerning suicidality. They mention (but fail to comment) that a 37% rise in unemployment was accompanied by an only 3% fall in GDP during 2009. In a previous publication it has been mentioned that unemployment and suicidality regression lines were identical concerning the US data [4], however they failed to mention that the rise in suicidality preceded for one year that of unemployment [5]. In the current paper it is interesting that they avoid plotting both the suicide rate and unemployment rate vs year in the same plot.
5. The authors report an excess of 4900 suicides in the year 2009 in comparison to their predictive model. However even if one looks closer at the data presented, significant increases in suicidal rates were observed for females only in 19 countries and in 33 for males (out of 54).
6. The hypothesis that the economic crisis is largely responsible for the increase observed in specific countries is in contrast with the reporting of the authors that a large portion of the increase concerns males aged 15-24 and the increase is smoothly distributed through the ages 15-64. It is also in sharp contrast to the recent finding that the increase in female suicides is mainly responsible for the increase in the suicide rate in Greece for the year 2011 [6].
7. In the discussion, concerning Greece, in spite of previous publications with overlapping authors [7-10], the authors of that paper fail to give the acurate picture of suicidality and mental health in Greece today [2 3 6 11 12].
Conclusively, it seems that suicides are increasing in the last few years. The population aged over 15 of the countries included in that study is roughly 1.1 billion people and the increase in suicides corresponds to around 0.44 per 105 residents. Since the average world suicide rate is above 10 and probably around 16 per 105 residents, this change is below 5% and probably non or marginally significant However this should not cover the fact that the trend is rather clear still premature to interpret. The role of the economic crisis and austerity is unclear, mainly because the data fluctuate with a period of decades, they manifest huge variability, peculiar changes in subgroups (e.g. mainly an increase in female suicides in Greece during 2011) and because the temporal correlations are problematic.
References
1. Chang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ 2013;347:f5239 doi: 10.1136/bmj.f5239
bmj.f5239 [pii][published Online First: Epub Date]|.
2. Fountoulakis KN, Grammatikopoulos IA, Koupidis SA, Siamouli M, Theodorakis PN. Health and the financial crisis in Greece. Lancet 2012;379(9820):1001-2; author reply 02 doi: 10.1016/S0140-6736(12)60422-X
S0140-6736(12)60422-X [pii][published Online First: Epub Date]|.
3. Fountoulakis KN, Siamouli M, Grammatikopoulos IA, Koupidis SA, Siapera M, Theodorakis PN. Economic crisis-related increased suicidality in Greece and Italy: a premature overinterpretation. J Epidemiol Community Health 2013;67(4):379-80 doi: 10.1136/jech-2012-201902
jech-2012-201902 [pii][published Online First: Epub Date]|.
4. Reeves A, Stuckler D, McKee M, Gunnell D, Chang SS, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012;380(9856):1813-4 doi: 10.1016/S0140-6736(12)61910-2
S0140-6736(12)61910-2 [pii][published Online First: Epub Date]|.
5. Fountoulakis KN, Koupidis SA, Siamouli M, Grammatikopoulos IA, Theodorakis PN. Suicide, recession, and unemployment. Lancet 2013;381(9868):721-2 doi: 10.1016/S0140-6736(13)60573-5
S0140-6736(13)60573-5 [pii][published Online First: Epub Date]|.
6. Fountoulakis KN, Koupidis SA, Grammatikopoulos IA, Theodorakis PN. First reliable data suggest a possible increase in suicides in Greece. BMJ 2013;347:f4900 doi: 10.1136/bmj.f4900
bmj.f4900 [pii][published Online First: Epub Date]|.
7. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381(9874):1323-31 doi: 10.1016/S0140-6736(13)60102-6
S0140-6736(13)60102-6 [pii][published Online First: Epub Date]|.
8. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Effects of Greek economic crisis on health are real. BMJ 2012;345:e8602; author reply e08 doi: 10.1136/bmj.e8602
bmj.e8602 [pii][published Online First: Epub Date]|.
9. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011;378(9801):1457-8 doi: 10.1016/S0140-6736(11)61556-0
S0140-6736(11)61556-0 [pii][published Online First: Epub Date]|.
10. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet 2011;378(9786):124-5 doi: 10.1016/S0140-6736(11)61079-9
S0140-6736(11)61079-9 [pii][published Online First: Epub Date]|.
11. Fountoulakis KN, Savopoulos C, Siamouli M, et al. Trends in suicidality amid the economic crisis in Greece. Eur Arch Psychiatry Clin Neurosci 2013;263(5):441-4 doi: 10.1007/s00406-012-0385-9[published Online First: Epub Date]|.
12. Fountoulakis KN, Pantoula E, Siamouli M, et al. Development of the Risk Assessment Suicidality Scale (RASS): a population-based study. J Affect Disord 2012;138(3):449-57 doi: 10.1016/j.jad.2011.12.045
S0165-0327(12)00003-1 [pii][published Online First: Epub Date]|.
Competing interests: No competing interests