Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries
We welcome the interest our study has generated. Unfortunately Fountoulakis and colleagues[1] continue to disregard statistical evidence, seeking to obscure the well-known links of recessions, job loss, and suicide risk.[2 3] Their misinterpretation of data from Greece, Italy and the USA has been previously demonstrated elsewhere;[4-7] briefly, their aggregated analysis of a few data points in single countries overlooks robust evidence that the observed suicide rises were a statistically significant deviation from past trends[5-7], concentrated in certain high-risk subgroups, including men,[5 8] and in countries with greater job losses.[8] They also miss the key point made by us[8] and others[9 10] that unemployment is only one of the determinants of crisis-related suicides, accounting for about one-quarter of the total observed suicide increase in the UK[9] and US.[11] Repeating their prior criticisms of our work, they also fail to acknowledge evidence contained in the current paper; for example, they question the temporal sequence between the rises in unemployment and suicide, requesting a graph showing trends in both. Webappendix figure 1 demonstrates clearly that the previous downward trend in male suicide reserved in 2009 following a reverse of the previous downward trend in unemployment in 2008, a finding in keeping with our previous analyses of time trends in unemployment and suicide in Europe.[12] Instead of continuing to deny evidence of a rise in suicide following the 2008 global economic crisis, the important public health issue is to understand how to prevent such avoidable recession related distress and suicide.
Laanani and colleagues[13] suggest that there is a need to estimate the variance of actual, observed suicide rates. Our study’s research question was to identify whether the observed numbers of suicides in the years of the recession deviated from historical trends (calculating 'excess' deaths). In our statistical models, we follow standard methods to account for uncertainty in estimating trends by assessing the variance in future projections, comparing expected values with actual observations. We acknowledge that theoretically there is additional uncertainty in observed suicide counts particularly amongst countries with a relatively small population size. However, our main results do not change when we take account of such uncertainty as an additional robustness check: as shown in webappendix table 1, the results based on data for all 54 countries were similar, showing a rise in male suicide, mainly in European and American countries studied. The country-specific estimates of rate ratios were comparable to our original results, although their confidence intervals were wider (webappendix table 2). Laanani et al. also suggest an impact of age interaction on our findings, whereas we have formally examined age-specific patterns in our analysis.[8]
Both Fountoulakis et al.[1] and Laanani et al.[13] draw attention to specific countries, whereas the key findings of our paper are on the overall impact on suicide of the economic crisis worldwide and the sex/age/region differences. Given the strong evidence for rising suicide rates following the recession, we believe that the priority for researchers should now be to identify the groups of people most affected and social protection measures that may offset the impact of economic downturn in these high risk groups.
Reference
1. Fountoulakis KN, Theodorakis P. Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ 2013 http://www.bmj.com/content/347/bmj.f5239/rr/665855.
2. Platt S, Hawton K. Suicidal behaviour and the labour market. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester, UK: John Wiley & Sons, Ltd, 2000:309-84.
3. Gunnell D, Platt S, Hawton K. The economic crisis and suicide. BMJ 2009;338:b1891.
4. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health and the financial crisis in Greece - Authors' reply. The Lancet 2012;379:1002.
5. Kondilis E, Ierodiakonou I, Gavana M, Giannakopoulos S, Benos A. Suicide mortality and economic crisis in Greece: men's Achilles' heel. J Epidemiol Community Health 2013;67:e1.
6. De Vogli R, Marmot M, Stuckler D. Strong evidence that the economic crisis caused a rise in suicides in Europe: the need for social protection. J Epidemiol Community Health 2013;67:298.
7. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Suicide, recession, and unemployment - Authors' reply. The Lancet 2013;381:722.
8. 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.
9. Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the 2008-10 economic recession in England: time trend analysis. BMJ 2012;345:e5142.
10. Hawton K, Haw C. Economic recession and suicide. BMJ 2013;347:
11. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Increase in state suicide rates in the USA during economic recession. The Lancet 2012;380:1813-14.
12. 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;378:124-5.
13. Laanani M, Walid Ghosn E, Jougla GR. Suicide increase during the 2008 economic recession: some methodological issues. BMJ 2013 http://www.bmj.com/content/347/bmj.f5239/rr/666152.
Competing interests:
No competing interests
31 October 2013
Shu-Sen Chang
Research assistant professor
David Stuckler, Paul Yip, David Gunnell
HKJC Centre for Suicide Research and Prevention, The University of Hong Kong
Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong SAR, China
Rapid Response:
Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries
We welcome the interest our study has generated. Unfortunately Fountoulakis and colleagues[1] continue to disregard statistical evidence, seeking to obscure the well-known links of recessions, job loss, and suicide risk.[2 3] Their misinterpretation of data from Greece, Italy and the USA has been previously demonstrated elsewhere;[4-7] briefly, their aggregated analysis of a few data points in single countries overlooks robust evidence that the observed suicide rises were a statistically significant deviation from past trends[5-7], concentrated in certain high-risk subgroups, including men,[5 8] and in countries with greater job losses.[8] They also miss the key point made by us[8] and others[9 10] that unemployment is only one of the determinants of crisis-related suicides, accounting for about one-quarter of the total observed suicide increase in the UK[9] and US.[11] Repeating their prior criticisms of our work, they also fail to acknowledge evidence contained in the current paper; for example, they question the temporal sequence between the rises in unemployment and suicide, requesting a graph showing trends in both. Webappendix figure 1 demonstrates clearly that the previous downward trend in male suicide reserved in 2009 following a reverse of the previous downward trend in unemployment in 2008, a finding in keeping with our previous analyses of time trends in unemployment and suicide in Europe.[12] Instead of continuing to deny evidence of a rise in suicide following the 2008 global economic crisis, the important public health issue is to understand how to prevent such avoidable recession related distress and suicide.
Laanani and colleagues[13] suggest that there is a need to estimate the variance of actual, observed suicide rates. Our study’s research question was to identify whether the observed numbers of suicides in the years of the recession deviated from historical trends (calculating 'excess' deaths). In our statistical models, we follow standard methods to account for uncertainty in estimating trends by assessing the variance in future projections, comparing expected values with actual observations. We acknowledge that theoretically there is additional uncertainty in observed suicide counts particularly amongst countries with a relatively small population size. However, our main results do not change when we take account of such uncertainty as an additional robustness check: as shown in webappendix table 1, the results based on data for all 54 countries were similar, showing a rise in male suicide, mainly in European and American countries studied. The country-specific estimates of rate ratios were comparable to our original results, although their confidence intervals were wider (webappendix table 2). Laanani et al. also suggest an impact of age interaction on our findings, whereas we have formally examined age-specific patterns in our analysis.[8]
Both Fountoulakis et al.[1] and Laanani et al.[13] draw attention to specific countries, whereas the key findings of our paper are on the overall impact on suicide of the economic crisis worldwide and the sex/age/region differences. Given the strong evidence for rising suicide rates following the recession, we believe that the priority for researchers should now be to identify the groups of people most affected and social protection measures that may offset the impact of economic downturn in these high risk groups.
Reference
1. Fountoulakis KN, Theodorakis P. Re: Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ 2013 http://www.bmj.com/content/347/bmj.f5239/rr/665855.
2. Platt S, Hawton K. Suicidal behaviour and the labour market. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester, UK: John Wiley & Sons, Ltd, 2000:309-84.
3. Gunnell D, Platt S, Hawton K. The economic crisis and suicide. BMJ 2009;338:b1891.
4. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health and the financial crisis in Greece - Authors' reply. The Lancet 2012;379:1002.
5. Kondilis E, Ierodiakonou I, Gavana M, Giannakopoulos S, Benos A. Suicide mortality and economic crisis in Greece: men's Achilles' heel. J Epidemiol Community Health 2013;67:e1.
6. De Vogli R, Marmot M, Stuckler D. Strong evidence that the economic crisis caused a rise in suicides in Europe: the need for social protection. J Epidemiol Community Health 2013;67:298.
7. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Suicide, recession, and unemployment - Authors' reply. The Lancet 2013;381:722.
8. 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.
9. Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the 2008-10 economic recession in England: time trend analysis. BMJ 2012;345:e5142.
10. Hawton K, Haw C. Economic recession and suicide. BMJ 2013;347:
11. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Increase in state suicide rates in the USA during economic recession. The Lancet 2012;380:1813-14.
12. 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;378:124-5.
13. Laanani M, Walid Ghosn E, Jougla GR. Suicide increase during the 2008 economic recession: some methodological issues. BMJ 2013 http://www.bmj.com/content/347/bmj.f5239/rr/666152.
Competing interests: No competing interests