Suicides in Greece before and during the period of austerity by sex and age group: Relationship to unemployment and economic variables

Behavioral and location-related antecedents of train suicides

BACKGROUND

In the European Union, over 2000 suicides on railway premises were reported in 2020. Identifying individuals' behavioral and location patterns just before they die or attempt to die by train suicide (ITS) is critical for effective prevention of suicides by train. We conducted a naturalistic study using a newly developed instrument for the assessment of fatalities in rail traffic that used information from on-site video cameras.

METHODS

A total of 56 case files and surveillance recordings of ITS prior to their suicide or suicide attempt were compared to 46 surveillance recordings of matched regular train passengers (RTP) before they boarded their trains. Groups were compared on individuals' behavior as well as location and contextual parameters.

RESULTS

ITS performed unusual movement patterns more frequently, carried luggage less often, stayed on the platform longer, and let more trains pass relative to RTP.

CONCLUSIONS

If this study is replicated with a larger sample, artificial intelligence could be used to detect suspicious/unusual (movement) patterns in order to prevent train suicide. Social awareness campaigns that foster the identification of people in distress at train stations in combination with lower thresholds for the use of emergency devices on platforms may help to detect potential train suicides and reduce their incidence.

Suicidality Related to the COVID-19 Lockdown in Romania: Structural Equation Modeling

Background

Suicidality is a serious public health concern at a global scale. Suicide itself is considered to be preventable death; worldwide, suicide rates and their trends are under constant scrutiny. As part of the international COMET-G cross-sectional study, we conducted a national level investigation to examine the individual disturbances (such as anxiety, depression, or history of life-threatening attempts) and contextual factors (such as adherence to conspiracy theories or Internet use) associated with suicidality related to the COVID-19 lockdown in a lot of Romanian adults.

Participants and Methods

One thousand four hundred and forty-six adults responded to an anonymous on-line questionnaire, with mean age ± standard deviation of 47.03 ± 14.21 years (1,142 females, 292 males, 12 identified themselves as non-binary). Data were analyzed using descriptive statistics and structural equation modeling (SEM).

Results

Univariate analysis showed strong significant correlation between anxiety and depression scorings among the respondents (Spearman R = 0.776, p < 0.001). Both the suicidality scorings and the Internet use correlated fairly with anxiety and depression, with two-by-two Spearman coefficients between R = 0.334 and R = 0.370 (p < 0.001 for each). SEM analysis substantiated the emotional disturbances, previous life-threatening attempts, and younger age as significant predictors for suicidality. The patterns of reality reading (including religious inquiries, Internet use, and beliefs in conspiracy theories) did not reach the statistical significance as influential factors in the suicidality of these respondents. There was no covariance between the Internet use and belief in conspiracy theories.

Conclusion

The study confirmed the suicidality risk initially hypothesized as being associated with the history of life-threatening attempts, increased depression within the younger population, and higher anxiety during the first year of the COVID-19 pandemic and its related lockdown. National strategies for effective interventions at various levels of the healthcare system should be developed.

The impact of macroeconomic factors on suicide in 175 countries over 27 years

BACKGROUND

Every year, more than 800,000 people die by suicide, three-quarters of which are males. Economic factors influence suicide rates, but a worldwide perspective of their impact according to age and sex is lacking.

METHOD

We queried publicly available datasets on economic factors and on suicide rates stratified according to sex and age, from 1991 to 2017, for 175 countries. Thus, we analyzed approximately 21 million deaths by suicide using a multivariable regression model approach.

RESULTS

Every 1% increase in global unemployment rates is associated with a 1% upsurge in male deaths by suicide (Relative risk (RR) = 1.01 [CI 95% 1.00-1.01] with respect to females) or 5000 excess male deaths. A 1% higher unemployment rate also exerts age-specific effects on suicide rates, since, among adults aged 30-59, the suicide rate is increased by 2-3%. Lastly, for every 1000 US dollar increase in the GDP per capita, suicide rates are reduced by 2% (RR = 0.98 [0.98-0.98]), corresponding to a reduction of 14,000-15,000 suicide deaths per year globally.

CONCLUSIONS

Males who have lost their jobs in adulthood are those at higher risk of suicide and to whom financial support measures should be delivered in a timely manner.

Suicide rates and institutional quality in an emerging country

Purpose

The purpose of this study is to investigate the relationship between suicide rates and institutional quality.

Design/methodology/approach

This study used autoregressive distributed lag model and error correction model to examine short-run and long-run relationships during 1996–2017 in Lebanon.

Findings

The study shows that in the long-run, suicide rates are significantly associated to the control of corruption, voice and accountability and rule of law, but not to regulatory quality, political stability and government efficiency. In the short-run, nearly all variables of institutional quality have a negative and significant relationship to suicide rates. Results are discussed in detail.

Originality/value

This research is the first to inspect the relation between the quality of institutions and suicide rates. Empirical results of this study add new evidence to the literature and provide support to policymakers.

Lost in transition: a systematic review of the association between unemployment and mental health

BACKGROUND

Unemployment can involve financial strain and major psychosocial challenges. Integration of the existing evidence is needed to better characterize the association between unemployment and mental health, independently of macroeconomic contexts.

AIMS

Main objectives of this study: (a) review, integrate, and summarize evidence about the association between unemployment and anxiety disorders, mood disorders, and suicidal behaviour, and (b) identify variables affecting this association.

METHOD

Systematic review of literature following PRISMA guidelines. PubMed, Web of Science, SciELO, RCAAP, and Cochrane Library databases were searched. Quantitative empirical studies on the association between unemployment and mental illness of community-based samples were included. The quality of the evidence provided in the studies was assessed following pre-defined methodological criteria.

RESULTS

Overall, 294 articles were considered eligible. In total, 55.7% of the studies were conducted in Europe; 91.4% supported a positive association between increased unemployment rates and anxiety, mood disorders, or suicidal behavior. Men and young adults were most severely affected by unemployment. Education and social support were found to buffer the negative outcomes of job loss.

CONCLUSIONS

Unemployment was inversely associated with mental health irrespectively of the economic context; unemployed individuals were more vulnerable to commit suicide and suffer from anxiety and mood disorders.

Economic crisis and stillbirth ratios: Evidence from Southern Europe

In this paper we assess the impact of the recent European recession on stillbirth indices over the course of the 2000s and 2010s; the analysis focuses on four Southern European countries (Greece, Italy, Spain, Portugal), which were seriously affected by the sovereign debt crisis from around 2008 to 2017. We use national vital statistics and established economic indicators for the period 2000-2017; stillbirth ratios (stillbirths per 1000 livebirths) are the chosen response variable. For the purpose of the study, we employ correlation analysis and fit regression models. The overall impact of economic indicators on the stillbirth indices is sizeable and statistically robust. We find that a healthy economy is associated with low and declining levels of stillbirth measures. In contrast, economic recession appears to have an adverse effect (Greece, Italy and Spain), or an unclear impact (Portugal), on the stillbirth outcome. This study provides evidence of the adverse effect of the European sovereign debt crisis and ensuing period of austerity on a scarcely explored aspect of health.

Employment and suicidal rates during economic recession: A country-targeted integrative review

BACKGROUND

The economic crisis' effects on suicide rates for countries undergoing or exiting austerity measures have been widely debated. This integrative review aimed to identify, appraise, and synthesize available evidence of employment status effect on suicide mortality rates in Greece during the recent economic recession period.

METHODS

A literature review of studies evaluating suicides in the general Greek population, as well as across age and gender groups, in relation to employment during the economic crisis period was performed. PubMed electronic database was searched for relevant articles published in English or Greek language from 2009 up to February 2020. Appraisal was carried out based on the Hierarchy of Evidence Rating System and the GRADE guidelines.

RESULTS

A total of 24 articles met all inclusion criteria with 20 of them at level IV, 2 at level VII, and 2 at level VIII. A total of 18 studies reported increase of suicide rates during the economic recession period. About 12 studies examined the co-relation between unemployment and suicide rate, with ten studies showing a positive correlation. Moreover, thirteen studies reported data on the effect of gender and age variables on suicide rates.

CONCLUSION

Evidence shows that suicide mortality rates in Greece increased after the eruption of economic recession, particularly after the implementation of radical austerity measures (2011-2014). This increase was positively correlated with unemployment and was more prominent among males of working age. Further in depth epidemiological research of regional variations in terms of profile and contributing or enabling factors of suicidal behavior is needed.

Help-seeking intentions in the U.S. population during the COVID-19 pandemic: Examining the role of COVID-19 financial hardship, suicide risk, and stigma

The primary goal of this study was to increase understanding of help-seeking intentions in the U.S. population during the COVID-19 pandemic and to examine influencing factors such as COVID-19 financial hardship, suicide risk, and stigma in order to contribute to effective theory-based help-seeking and suicide prevention campaigns. In a representative sample of U.S. adults (N = 5,010), this research tested whether COVID-19 financial hardship was associated with higher levels of depression and suicidal ideation (supported), and whether the reasoned action framework could usefully predict help-seeking intentions in this context (supported). The reasoned action framework explained 36% of the variance in help-seeking intentions in the U.S. population and identified injunctive norm (social support) as primary determinant of intention. Neither suicidal ideation, COVID-19 financial hardship, or self-stigma of seeking help influenced determinants of help-seeking. Future research should test injunctive norm as causal predictor of help-seeking in the U.S. population to usefully inform effective help-seeking campaigns, particularly among those who have experienced COVID-19 financial hardship. Additionally, effective dissemination strategies for help-seeking campaigns should be tested and identified, such as broader targeted approaches as well as intentional mis-targeting techniques.

[The global impact of the COVID-19 pandemic on the care provision for people with mental health problems]

There are increasingly comprehensive data on recognition of the psychological impact of the coronavirus disease 2019 (COVID 19) pandemic on global populations. In most regions of the world, the economic and psychological burden on the general population and persons with mental disorders has risen sharply over the course of the pandemic. Beyond anxieties regarding severe acute respiratory syndromes due to coronavirus type 2 (SARS-CoV-2) infections, in many countries the measures for containing the pandemic also led to psychological burdens. It was shown that social distancing and contact restrictions were risk factors for the development or deterioration of mental health problems on a global scale. Simultaneously, the COVID-19 pandemic has disrupted or reduced mental health services in many countries. Thus, there is a substantial need for low threshold offers of assistance and for coping strategies. Current studies could show that certain coping strategies, such as virtual social contacts and physical activity, appear to be useful in counteracting the negative psychological sequelae of the pandemic; however, in order to improve care provision for people with psychological burden and mental illness in the medium term, it is necessary to offer targeted treatment, such as online psychotherapy in particular. Collaborative research tackles poverty, social isolation and loneliness.

Suicidal ideation during COVID-19 lockdown in Greece: Prevalence in the community, risk and protective factors

The aim of this study was to investigate the prevalence of suicidal ideation in the community as well as the risk and protective factors of suicidal ideation during restriction measures in Greece, after the outbreak of the COVID-19 pandemic. Α web-based anonymous survey was conducted during the first lockdown period. Participants completed the Generalized Anxiety Disorder scale (GAD-2), the Patient Health Questionnaire (PHQ-2), the Systemic Clinical Outcome and Routine Evaluation (SCORE-15), the Connor-Davidson Resilience Scale (CD-RISK-2), and a self-report questionnaire for COVID-19 pandemic-related data. From a total of 5,116 adults included in the study, 5.20% reported suicidal thoughts, 14.17% were potential clinical cases of anxiety, and 26.51% of depression. Participants presented significantly higher suicidal ideation rates during the last two weeks of the lockdown compared to its previous two weeks. Unmarried or divorced marital status, mental health history, poor perceived quality of physical health, impaired family functioning, anxiety and depression symptoms were independently associated with higher odds of suicidal ideation, whereas higher resilience, positive feelings with regard to the lockdown measures, relationship with friends, and faith in a Supreme Being were associated with lower suicidal ideation odds. According to the findings, suicidal ideation prevalence might be considered elevated and its increase during the lockdown period alarming. The risk and protective factors identified in the study offer valuable information for the development of preventive strategies against suicidal ideation, especially in times of crisis.

Characteristics of completed suicides after Greek financial crisis onset: A comparative time-series analysis study

Severe financial crises could influence a country's suicide trends and characteristics. We aimed to highlight differences among suicide completers before and after the onset of Greece's serious debt crisis of 2010 based exclusively on forensic data. The sample's size permitted a further elaboration by means of a time series analysis too. Data were collected from the Piraeus Department of Forensic Medicine for the period 1992-2016. We extracted information on sociodemographic parameters, psychiatric medication and alcohol intake, suicide method, place and month of suicide. The "after crisis onset" group (2011-2016) was significantly older (p = 0.039)-primarily due to differences in the 55-64 age group-, had more frequently used psychiatric medications (p < 0.001), less often alcohol (p = 0.001) and died more frequently by immolation (p = 0.001). These differences were-almost exclusively-due to changes regarding male suicidal behavior. Time series analysis indicates that no strong increasing trend in total (male + female) suicide count can be observed, despite a local increase in 2009-2010. Antidepressant-positive suicides show an increase after 2010, whereas alcohol-positive suicides show a decrease. Future predicted forecasts for antidepressant-positive suicides indicate a decrease (from 5.6 per year in 2018 to 4.3 per year in 2025) whereas an increase is predicted in alcohol-positive suicides (7.7 per year in 2017, 9.36 per year in 2025). Middle-aged men, compared to middle-aged women, presumably found it harder to adjust to economic hardship after the crisis onset. Finally, comparatively more men than women who died by suicide appear to have started and/or complied with psychiatric treatment after 2010.

Increased Psychological Distress, Loneliness, and Unemployment in the Spread of COVID-19 over 6 Months in Germany

Background: The COVID-19 pandemic poses a challenge to global mental health. Loneliness and isolation may put people at higher risk for increased psychological distress. However, there is a lack of research investigating the development of COVID-19-related distress over time. Materials and Methods: We undertook an online survey among general population (N = 1903) in Germany throughout 6 months from the peak transmission period in April to the off-peak period by September 2020. Results: We found that the average prevalence of psychological distress caused by the COVID-19 pandemic significantly rose from 24% to 66% between the peak and off-peak transmission period, respectively. Unemployment rate and loneliness increased negative mental health outcomes, although the number of active COVID-19 cases decreased from April to September. Psychological distress scores increased mostly in female, young, and lonely people. Conclusions: Our results underline the importance of considering innovative alternatives to facilitate employment opportunities, distant contacts, and self-help over the course of the pandemic. Our study highlights the urgent need to pay attention to mental health services specifically targeting female, young, unemployed, and lonely people.

Self-immolation Suicide in Greece: A Forensic Psychiatric Autopsy Study between 2011 and 2019

Self-immolation is a rare suicide method in the developed countries of the western world (0.06-1%); however, it has relatively higher prevalence rates in the developing countries of Asia and Africa (6-57%). The present study aims to examine self-immolation suicides within the Greek mainland (Attiki, Thrace, and Peloponnese) over a period of 9 years (2011-2019) in order to investigate the phenomenon in the Greek population forensically, identify the characteristics and motivations of suicide victims, explore its associations to socio-cultural or psychiatric factors, and describe a fatal case of suicide by self-immolation that was partially recorded on camera. The medical files (autopsy reports) of cases performed at the Departments of Forensic Medicine of the National and Kapodistrian University of Athens, Democritus University of Thrace, and the Forensic Service of Messinia-Peloponnese were retrospectively examined yielding 19 cases of suicides by self-immolation. A 3.7% prevalence of suicide by self-immolation among suicide fatalities within the Greek population was estimated. A distinctive feature of the Greek population regarding self-immolation was disclosed that it is being practiced predominantly by the elderly (mean age 2-3.5 decades higher than other countries). The phenomenon correlated strongly with poorly controlled mental disorders (mostly affective and adjustment disorders). Unlike other countries, there was no significant association with domestic or sexual violence, social or political protest, or religious issues. Therefore, the suicide victims preferred secluded or private outdoor locations (not public). Findings deriving from the examined variables localize Greek population culturally between the Western European and Asian African countries, but with its own idiosyncrasies.

Health-related Sustainable Development Goals: countdown on alcohol use, smoking prevalence, child overweight and suicide mortality

The Sustainable Development Goals (SDGs) are a set of goals that aspire to 'leave no one behind', adopted by all members of the United Nations and to be achieved by 2030. Now, four years after the SDGs entered into force, we examine the progress towards the health-related SDGs in the European region. In this region, least progress is made towards the targets set for alcohol consumption, smoking prevalence, child overweight, and suicide mortality. For each of these challenges we take stock of current policies, continuing challenges, and ways forward. Written from the perspective of European Public Health Association (EUPHA) we emphasize the potential contribution of civil society organizations in attaining the health-related SDGs.