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Health outcomes during the 2008 financial crisis in Europe: systematic literature review

BMJ 2016; 354 doi: (Published 06 September 2016) Cite this as: BMJ 2016;354:i4588
  1. Divya Parmar, lecturer1,
  2. Charitini Stavropoulou, senior lecturer1,
  3. John P A Ioannidis, professor2
  1. 1School of Health Sciences, City University London, London EC1V 0HB, UK
  2. 2School of Medicine, Stanford University, Stanford, CA, USA
  1. Correspondence to: C Stavropoulou C.Stavropoulou{at}
  • Accepted 20 July 2016


Objective To systematically identify, critically appraise, and synthesise empirical studies about the impact of the 2008 financial crisis in Europe on health outcomes.

Design Systematic literature review.

Data sources Structural searches of key databases, healthcare journals, and organisation based websites.

Review methods Empirical studies reporting on the impact of the financial crisis on health outcomes in Europe, published from January 2008 to December 2015, were included. All selected studies were assessed for risk of bias. Owing to the heterogeneity of studies in terms of study design and analysis and the use of overlapping datasets across studies, studies were analysed thematically per outcome, and the evidence was synthesised on different health outcomes without formal meta-analysis.

Results 41 studies met the inclusion criteria, and focused on suicide, mental health, self rated health, mortality, and other health outcomes. Of those studies, 30 (73%) were deemed to be at high risk of bias, nine (22%) at moderate risk of bias, and only two (5%) at low risk of bias, limiting the conclusions that can be drawn. Although there were differences across countries and groups, there was some indication that suicides increased and mental health deteriorated during the crisis. The crisis did not seem to reverse the trend of decreasing overall mortality. Evidence on self rated health and other indicators was mixed.

Conclusions Most published studies on the impact of financial crisis on health in Europe had a substantial risk of bias; therefore, results need to be cautiously interpreted. Overall, the financial crisis in Europe seemed to have had heterogeneous effects on health outcomes, with the evidence being most consistent for suicides and mental health. There is a need for better empirical studies, especially those focused on identifying mechanisms that can mitigate the adverse effects of the crisis.


  • We thank Maria Raisa Jessica Aquino for helping with the initial literature search.

  • Contributors: DP and CS were involved in the initial conception and design of the study. DP secured funding. DP and CS developed the search strategy and extracted data from included studies. DP and CS were involved in the data analysis. DP, CS, and JPAI developed the assessment of risk of bias tool. DP, CS, and JPAI were involved in the interpretation and discussion of results. CS developed the first draft of the manuscript and all authors critically revised it and approved the final version. DP and CS are co-first authors and study guarantors. Maria Raisa Jessica Aquino contributed to the initial literature search as a non-author.

  • Funding: The study was financially supported by a pump priming scheme from the School of Health Sciences at City University London. The funder was not involved in the research and preparation of the article, including study design; collection, analysis, and interpretation of data; writing of the article; nor in the decision to submit it for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: the study was financially supported by a pump priming scheme from the School of Health Sciences at City University London; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

  • The lead authors affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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