Impact of 2008 global economic crisis on suicide: time trend study in 54 countriesBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5239 (Published 17 September 2013) Cite this as: BMJ 2013;347:f5239
All rapid responses
We welcome the interest our study has generated. Unfortunately Fountoulakis and colleagues 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. They also miss the key point made by us 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 and US. 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. 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 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.
Both Fountoulakis et al. and Laanani et al. 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.
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
Chang et al’s study  provides challenging information on the impact of the 2008 economic crisis on suicide mortality in a very large sample of countries. It is the first assessment of this impact with a constant method across different countries all over the world. Nevertheless, we would like to draw readers’ attention to some methodological issues.
Firstly, according to what is explained by Chang et al in their paper, we can deduce that the confidence intervals of the rate ratios of suicides in 2009 were estimated on the basis of the variance of the expected number of suicides in 2009 if 2000-2007 trends had continued. However, the variance of the rate ratio of suicides depends not only on the variance of the expected number of suicides, but also on the variance of the observed number of suicides. Under the null hypothesis that there was no crisis effect, the observed number of suicides in 2009 is supposed to follow, as in previous years, an overdispersed Poisson distribution, and hence, to have a variance of larger magnitude than the expected number of suicides. Not taking into account this part of the variance could be, in a way, comparable to not taking into account the number of cases in the estimation of the confidence interval of an odds ratio in a case-control study. We compared Chang et al’s results with a more conventional method on a sample of eight EU countries (Austria, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK). In the Table, we present:
A - the results published in Chang et al’s paper (we found closely comparable results when we reproduced their model);
B - the results of the most conventional way to estimate the rate ratio and its confidence interval, with a negative binomial log-linear model including a dummy variable for 2009.
The 95% confidence intervals of the rate ratios obtained with the model used in (B) take into account the variance of the observed number of suicides. In the eight analysed countries, when Chang et al found significant associations in men in all countries, and in Austrian, Finnish, and Dutch women, we found no significant association in women, and a significant association only in German, Spanish and British men. The confidence intervals found by Chang et al may therefore be too small, and may conduce to spurious conclusions.
Secondly, we found that the results seem to be very sensitive to the model used. In particular, they vary according to the interaction terms included in the model (e.g. a specific time trend by age). It seems difficult to find the model that fits better to the observed data of mortality, and that takes the necessary interactions into account. The inconsistency of the association between suicide mortality and the 2008 economic crisis according to the statistical methodology was already described in England: divergent associations were found by Barr et al  and Saurina et al . Saurina concluded that the inconsistency of the estimates may result from a lack of control for potential confounders.
Thirdly and finally, Chang et al suggested that their results were in favour of a dose-response effect of unemployment on suicide mortality. The individual unemployment-suicide association has already been well documented: the risk of suicide is increased among the unemployed, but this may be a combination of causal and self-selection processes (with notably the impact of psychiatric disorders) . Ecological studies on mortality databases, as Chang et al's study, are not designed to assess an individual link, but the combination between an individual and a contextual (macro-social) effect. In 1990, Crombie hypothesized that unemployment does not explain all the rise in suicide mortality during increasing unemployment periods, and that the unexplained part could result from the more generalized effects of economic recession . Then he concluded that an increase in suicide rates is not an inevitable consequence of increased unemployment.
Thus, if unemployment explains probably a part of suicide increase during the 2008 economic crisis, it remains to identify the other factors explaining this increase, in order to implement efficient prevention policies targeting these factors. One of these factors could be the prevalence of psychiatric disorders and the quality and effectiveness of their treatment . Another explanation could be the impact of suicide reporting in the media, with an imitative effect (also called Werther effect) which has been largely reported . The World Health Organization published guidelines for media professionals to limit these side effects . In opposition, a protective effect (called Papageno effect) of reporting positive behaviour in adverse circumstances has also been reported .
The association between the 2008 crisis and the increase in suicide rates has to be considered with care. Multiple causes may be involved, not only the rises in unemployment rates, and these factors can have an impact at an individual and/or a contextual scale. We have to be particularly careful on the statistical method used, as finding too small confidence intervals may lead to premature conclusions.
1. Chang S-S, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ. 2013;347:f5239–f5239.
2. 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.
3. Saurina C, Bragulat B, Saez M, López-Casasnovas G. A conditional model for estimating the increase in suicides associated with the 2008-2010 economic recession in England. J. Epidemiol. Community Health. 2013;
4. Hawton K, van Heeringen K. The International Handbook of Suicide and Attempted Suicide. Chichester, England: John Wiley & Sons, Ltd; 2000.
5. Crombie IK. Can changes in the unemployment rates explain the recent changes in suicide rates in developed countries? Int. J. Epidemiol. 1990;19:412–6.
6. Gusmão R, Quintão S, McDaid D, Arensman E, Van Audenhove C, Coffey C, et al. Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study. PloS One. 2013;8:e66455.
7. Preventing Suicide: A Resource for Media Professionals. WHO; 2008.
8. Niederkrotenthaler T, Voracek M, Herberth A, Till B, Strauss M, Etzersdorfer E, et al. Media and suicide. Papageno v Werther effect. BMJ. 2010;341:c5841.
Competing interests: No competing interests
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
WHO National Counterpart for Mental Health, Greece
Recently a study on the relationship of the 2008 global economic crisis on suicide has been published by the BMJ . 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 . Similar issues have been raised concerning the interpretation of data from other countries .
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 , however they failed to mention that the rise in suicidality preceded for one year that of unemployment . 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 .
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.
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
Severe economic crisis has increased the number of people suffering from major depressive disorder (MDD) by 50 percent, resulting in a monthly prevalence which amounts to 12.3% of the Greek population, a study of the University Research Institute of Mental Health (EPIPSI) of the University of Athens concluded. 
50 percent of Greeks with low family incomes met the criteria of depression.
The Greek statistical agency (ELSTAT) reported a 43% rise in suicides during crisis. 
The NGO Klimaka announced that many more suicides go undocumented, because they are reported as accidents by relatives anxious to avoid social and religious stigma, and obtain a proper free religious burial.
In the meantime, the Greek NHS seems unable to sustain financially Psychiatric Hospitals and shuts them down. 
Competing interests: No competing interests
The article by Chang et al  and the accompanying editorial by Hawton and Haw  examining the proximal effects of the global economic crisis of 2008 on international trends in suicide adds to the extant literature showing a direct relationship between the macroeconomic environment and mental health outcomes.
Chang et al  found that after the crisis of 2008, rates of suicides increased in European and American countries, particularly in men, where the baseline unemployment rates were low. Stuckler et al  have previously shown that for every 1% increase in unemployment, there was an increase in under-65 suicides of 0.79% in 26 European Union countries between 1970 and 2007. Most interestingly, they found that increased investment in active labour market programmes reduced the effect of unemployment on suicides, demonstrating a possible cause - effect relationship between the two. Hawton and Haw  also rightly point out that restriction of sickness, disability, child and housing benefits may directly contribute to these excess suicides. It should be noted that unemployment affects not just proximal measures like suicide and rates of mental health in adults.
It also has an impact on more distal outcomes, and across generations. For example, Ramanathan et al  using the National Longitudinal Survey of Youth 1997 (NLSY97) cohort found that exposure to a 1% deviation from mean regional unemployment rates during infancy was associated with an increase in the odds ratios of engaging in marijuana use (OR=1.09) smoking (OR=1.07), alcohol use (OR=1.06), arrests (O.R.=1.17), gang affiliation (O.R.=1.09), and petty (O.R.=1.06) and major theft (O.R=1.11) during adolescence (age 12 to 16 years). Unfavourable macroenvironment (particularly high unemployment rates) therefore can have serious immediate as well as long term consequences across the lifespan, and more importantly across generations. The two articles in the most recent issues are most timely and have serious direct implications, particularly pertaining to future financial policies and their consequences on mental health and wellbeing across the life span.[1,2] In addition, they also warrant exploration of potential pathways through which macroeconomic environments may impact long term mental health outcomes, both in children and adults.
1. Chang S-S, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ 2013;347:f5239.
2. Hawton, K., Haw, C., Economic recession and suicide. BMJ 2013;347:f5612
3. Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., McKee, M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis . Lancet 2009; 374: 315–23
4. Ramanathan, S., Balasubramanian, N., Krishnadas, R. Macroeconomic environment during infancy and risk of adolescent behavioural problems. JAMA Psychiatry 2013; 70(2):218-225.
Competing interests: No competing interests
useful study as a flag waver!
but few questions;
1. was unemployment a factor or cofactor inflicting suicidal resort in victims
2. if suicidal response is morbid, is unemployment merely a tip of the iceberg in an inductive pressure complex that ultimately tipped the scale in the morbid direction
3. what are the personality types of these victims.
4. how does the personality type affect employability or unemployablity even if other factors ( including economics) had been favourable.
4. to what extent is unemployment a distinct precipitant for suicide as opposed to unemployment associated with poor living standards; is it the unemployment or the resulting poor conditions or both that determine ultimate outcome or is there a relative weighting that needs working out?.
5. does chronic individual unemployment have same impact with acute individual unemploymentif the socio economic spin offs are not different; i could be unemployed but with good support system( family or public or church etc); will chronicity tip the scale even with good and enduring support system?
6. won't inclusion of countries in less developed countries with poor baseline employment and poor baseline public( as opposed to extended family) support system help to shed light into some of these areas.
Competing interests: No competing interests