Cause and effect in studies on unemployment, mental health and suicide: a meta-analytic and conceptual review

Work-related suicide: Evolving understandings of etiology & intervention

Previously published analyses of suicide case investigations suggest that work or working conditions contribute to 10%-13% of suicide deaths. Yet, the way in which work may increase suicide risk is an underdeveloped area of epidemiologic research. In this Commentary, we propose a definition of work-related suicide from an occupational health and safety perspective, and review the case investigation-based and epidemiologic evidence on work-related causes of suicide. We identified six broad categories of potential work-related causes of suicide, which are: (1) workplace chemical, physical, and psychosocial exposures; (2) exposure to trauma on the job; (3) access to means of suicide through work; (4) exposure to high-stigma work environments; (5) exposure to normative environments promoting extreme orientation to work; and (6) adverse experiences arising from work-related injury or illness. We summarise current evidence in a schema of potential work-related causes that can also be applied in workplace risk assessment and suicide case investigations. There are numerous implications of these findings for policy and practice. Various principle- and evidence-based workplace intervention strategies for suicide prevention exist, some of which have been shown to improve suicide-prevention literacy, reduce stigma, enhance helping behaviours, and in some instances maybe even reduce suicide rates. Prevailing practice in workplace suicide prevention, however, overly emphasises individual- and illness-directed interventions, with little attention directed to addressing the working conditions that may increase suicide risk. We conclude that a stronger emphasis on improving working conditions will be required for workplace suicide prevention to reach its full preventive potential.

A systematic review of effective local, community or peer-delivered interventions to improve well-being and employment in regional, rural and remote areas of Australia

OBJECTIVE

To systematically review evaluated local, community or peer-delivered well-being and employment interventions delivered within regional, rural and remote Australia.

DESIGN

Searches within nine databases retrieved peer-reviewed and grey literature from an initial pool of 3186 papers published between 2012 and 2022. PRISMA guidelines were adhered to, and the Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the well-being or employment (or both) articles.

FINDINGS

A total of 19 items met the inclusion criteria, which included two quantitative, 12 qualitative and five mixed-methods evaluations. Intervention cohorts included Indigenous Australians, youth, older people, workers and the general community. The average methodological rating was 83%. The overall level of evidence for the interventions was low due to mostly descriptive studies.

DISCUSSION

Interventions that appeared effective in improving well-being tended to focus on addressing social connectedness and self-determination. Unexpected employment outcomes were evident across many of the studies, which highlighted the reciprocity between well-being and employment.

CONCLUSION

This review highlights promising interventions for improving well-being by focusing on social connectedness and self-determination. Further empirical evidence is encouraged to explore the reciprocal relationship between well-being and employment, emphasising the significance of social connectedness and self-determination in this context.

Work-Related Cognitive Behavioral Therapy for racially and economically diverse unemployed persons with social anxiety: A randomized clinical trial

Individuals with Social Anxiety Disorder (SAD) are at risk for employment problems. This multi-site trial examined the efficacy of Work-Related Cognitive Behavioral Therapy provided alongside vocational services as usual (WCBT+VSAU), a group-based treatment designed to improve mental health and employment outcomes for individuals with SAD. Vocational service-seeking participants with SAD (N = 250) were randomized to either WCBT+VSAU or VSAU-alone. Hypotheses were that participants randomized to WCBT+VSAU would report less social anxiety, less depression, and more hours worked than participants randomized to VSAU-alone. WCBT+VSAU participants had significantly greater improvements on the Liebowitz Social Anxiety Scale (LSAS; d=-.25, CI=-0.49 to -0.02, p = .03) at post-assessment compared to VSAU-alone. The conditions did not differ on any variable at later time points or on secondary outcomes. Unexpectedly, participants randomized to VSAU-alone experienced LSAS improvements, similar to WCBT+VASU at later timepoints. Baseline psychological flexibility (beta=-.098 [-0.19-0.008]) and depression (beta=-0.18 [-0.34-0.009]) moderated change in social anxiety. Participants with lower psychological flexibility and higher depression responded more strongly to WCBT+VSAU than VSAU-alone over the duration of the study, suggesting that WCBT+VSAU may particularly benefit those with greater psychopathology. Results indicate that vocational centers are promising settings for treating SAD and employment-focused refinements are likely needed to improve work outcomes.

Overindebtedness, unemployment, and poor mental health - and the role of sense of control: a population-based Swiss study

Background

Both overindebtedness and unemployment are critical life events that can result in or lead to poor mental health. What is less known is that the two partly interrelated events frequently go along with a feeling of loss or lack of control in life, which could be the main reason why they are associated with poor mental health. This has not been examined in previous research, particularly not in this combination.

Methods

This study used and merged two cross-sectional data sets. Data collected in 2019 on 219 overindebted clients of the four official debt advisory centers in the Canton of Zurich were linked with a comparable subsample of 1,997 respondents from the Swiss Health Survey of 2017. The entire study population covered 2,216 adult individuals living in the Canton of Zurich.

Results

The prevalence of no or low sense of control, medium to high psychological distress, and moderate to major depression was much higher among the 44 solely unemployed (36/30/12%), the 189 solely overindebted (73/83/53%), and particularly among the 30 unemployed and overindebted (93/97/60%) than among all 1,953 other survey participants (21/13/7%). Unemployment, overindebtedness, and a (resulting) lack or loss of control were all found to be strong risk factors for the two mental health outcomes under study. Associations, or rather negative health effects, were partly but not fully mediated by the sense of control. Overindebtedness much more strongly predicted psychological distress (ß = -0.37) and depression (ß = 0.17) than unemployment (ß = -0.05/0.01). The sense of control turned out to be an independent explanatory factor for poor mental health and even the strongest of all (ß = 0.49/-0.59).

Conclusion

Improving a person's control beliefs could be a promising measure for preventing mental health disorders in general and in people who are unemployed and/or overindebted in particular.

Sex-related inequalities in crude and age-standardized suicide rates: trends in Ghana from 2000 to 2019

BACKGROUND

Suicide represents a major public health concern, affecting a significant portion of individuals. However, there remains a gap in understanding the age and sex disparities in the occurrence of suicide. Therefore, this study aimed to investigate the sex-related inequalities in suicide rates in Ghana from 2000 to 2019.

METHODS

We utilized data from the WHO Health Equity Assessment Toolkit (HEAT) online software. We analysed sex differences in both crude and age-standardized suicide rates in Ghana spanning from 2000 to 2019. Crude and age-adjusted suicide rates were calculated based on the International Classification of Diseases (ICD) definition and coding of suicide mortality. We measured inequality in terms of sex. Two inequality indicators were used to examine the suicide rates: the difference (D) and the ratio (R).

RESULTS

Age-standardized and crude suicide rates in Ghana were higher among men from 2000 to 2019. Between 2000 and 2007, the age-standardized suicide rate for women rose steadily and declined slightly between 2008 and 2019. Age-standardized suicide rates for men increased consistently from 2000 to 2010, then declined steadily from 2011 to 2019. The crude suicide rates among men and women followed similar patterns. The widest absolute inequality in crude suicide rates (D) was recorded in 2013 (D=-11.91), while the smallest difference was observed in 2000 (D=-7.16). We also found the greatest disparity in age-standardized rates in 2011 (D=-21.46) and the least in 2000 (D=-14.32). The crude suicide rates increased with age for both men and women aged 15-54 years and 55-85+ years respectively. However, the increased rate was higher in men than in women across all age groups surveyed. A similar pattern was observed for relative inequality in both crude and age-standardized rates of suicide.

CONCLUSION

The suicide rate in Ghana has declined over time. Suicide is more common among older men. Inequalities in suicide rates, in both absolute and relative terms, are similar. There is a need to monitor suicide trends in Ghana, especially among older men. Moreover, the findings could serve as a basis for future studies on suicide in Ghana.

Career progression for autistic people: A scoping review

LAY ABSTRACT

Lots of autistic people are unemployed. Even when they are employed, autistic people might be given fewer opportunities than non-autistic people to progress in their careers. For example, assumptions about autistic people's differences in social communication might mean they are not given as many promotions. Indeed, we know that many autistic people are in jobs lower than their abilities (known as 'underemployment'). We reviewed 33 studies that tell us something about career progression for autistic people. Our review found that lots of autistic people want to progress in their careers, but there are many barriers in their way. For example, when they told their employer about being autistic, some people were given fewer opportunities. Research has also shown that autistic people do not get enough support to progress and that gaps in their employment history can make it difficult to progress. Our review suggested that good employment support (e.g. mentors) might help autistic people to progress in their careers. However, not much research has evaluated employment support for autistic people, which means we do not know how useful it is. Future research should find the best support that allows autistic people to live and work in ways that are meaningful to them.

Attributable risk of suicide for populations in Australia

Objective

Each year approximately 3,000 Australians die by suicide. We estimated the population attributable risk for identified target populations to provide evidence on how much of the overall burden of suicide in the Australian population is experienced by each of them.

Methods

We identified 17 demographic and clinical target populations at risk of suicide and calculated the population attributable fraction (PAF) using a single or pooled suicide risk and the proportional representation of each target population within Australia.

Results

Large PAF estimates were found for men (52%, 95% confidence interval (CI) 51%-53%), people bereaved by suicide (35%, 95% CI 14%-64%), people with a mental health or behavioural condition (33%, 95%CI 17%-48%), people with a chronic physical condition (27%, 95%CI 18%-35%), adults aged 25-64 years (13%, 95%CI 12%-14%), LGB populations (9%, 95%CI 6%-13%), offenders (9%, 95%CI 8%-10%), and people employed in blue collar occupations (8%, 95%CI 4%-12%).

Limitations

The PAF is limited by assumptions, namely, that risk factors are independent, and that the relationship between risk factors and outcomes are unidirectional and constant through time.

Conclusions and implications for public health

Considerable reductions in the overall suicide rate in Australia may occur if risk factors are addressed in identified populations with large PAF estimates. These estimates should be considered as an adjunct to other important inputs into suicide prevention policy priorities.

Social Determinants of Mental and Behavioral Health

Both mental illness and overall mental health are determined by a complicated interplay of life experiences and genetic predisposition. While genetic predisposition is difficult to modify, many of the life experiences that worsen mental health and exacerbate serious mental illness are associated with social policies and cultural norms that are changeable. Now that we have identified these associations, it is time to rigorously test scalable interventions to address these risks. These interventions will need to focus on high-impact stages in life (like childhood) and will need to address risk beyond the individual by focusing on the family and community.

Financial Stress, Unemployment, and Suicide - A Meta-Analysis

Background: Socioeconomic factors such as financial stress and unemployment are known predictors of suicide. However, no large-scale meta-analyses exist. Aims: Determine the suicide risk following unemployment or financial stress. Method: Literature searched through July 31, 2021. Robust meta-analysis and metaregression of the risk of suicide following financial stress (23 studies) or unemployment (43 studies), from 20 nations. Subgroup meta-analyses by sex, age, year, country, and methodology. Results: The suicide risk following financial stress or unemployment was not significantly elevated among those with diagnosed mental illness. In the general population, we found significantly elevated suicide risks for financial stress (RR: 1.742; 95% CI: 1.339, -2.266) and unemployment (RR: 1.874; CI: 1.501, -2.341). However, neither was significant among studies controlling for physical/mental health (perhaps partially due to lower statistical power). We observed no significant differences by sex, age, or by GDP. We observed a higher suicide risk following unemployment in more recent years. Limitations: Publication bias was evident. We could not examine some individual-level characteristics, most notably the severity/duration of unemployment/financial stress. Heterogeneity was high for some meta-analyses. Studies from non-OECD countries are under-represented. Conclusion: After accounting for physical/mental health, financial stress and unemployment weakly associated with suicide, and the associations may be nonsignificant.

Revisiting the work-suicide link: renewed evidence and models of analysis in workplace contexts

Suicide is a priority public health problem for the World Health Organization. It is a multifactorial phenomenon, for which there is no effective strategy for prevention and reduction. The scientific knowledge generated has not paid much attention to the differentiating role of work and employment on the phenomenon of suicide. This article first presents Abrutyn's recent conceptual model of suicide, which has a psychosocial, holistic and integrated approach. Based on this model, it examines the most recent and solid evidence and trends linking working conditions and phenomenon of suicide, identifying the most relevant findings in work stress theories. It concludes by pointing out avenues of development for a more holistic and ecological understanding of suicide.

Results from a Nationwide Evaluation Study of Labor Market-Integrative Health Promotion for the Unemployed: Impact of the JOBS Program Germany

Compared to the employed, the unemployed suffer from poorer health, especially in terms of mental health. At the same time, health promotion rarely reaches unemployed people. The "JOBS Program" is an intervention to promote health and labor market integration and has shown positive effects in the USA and Finland. In this confirmatory study, we investigated whether the JOBS Program achieves similar effects in Germany. We applied a randomized controlled trial to compare an intervention group (IVG) with a waiting control group (WCG) before (T0; N = 94) and shortly after (T1; n = 65) the intervention. Concerning our primary outcomes, the JOBS Program Germany was beneficial: Compared to the WCG, the regression estimated that the IVG had (1) a 2.736 scale point higher level of life satisfaction (p = 0.049), (2) a 0.337 scale point higher level of general health (p = 0.025), and (3) a 14.524 scale point higher level of mental well-being (p = 0.004). Although not statistically significant, job search-specific self-efficacy also appeared to be positively associated with the intervention. This study provides evidence of the effectiveness of JOBS Program on the abovementioned outcomes, including for older and long-term unemployed people, supporting the benefits of regular implementation of this program for a wide range of unemployed people in Germany.

Unemployment and underemployment are causes of suicide

Epidemiological studies indicate that labor underutilization and suicide are associated, yet it remains unclear whether this association is causal. We applied convergent cross mapping to test for causal effects of unemployment and underemployment on suicidal behavior, using monthly data on labor underutilization and suicide rates in Australia for the period 2004-2016. Our analyses provide evidence that rates of unemployment and underemployment were significant drivers of suicide mortality in Australia over the 13-year study period. Predictive modeling indicates that 9.5% of the ~32,000 suicides reported between 2004 and 2016 resulted directly from labor underutilization, including 1575 suicides attributable to unemployment and 1496 suicides attributable to underemployment. We conclude that economic policies prioritizing full employment should be considered integral to any comprehensive national suicide prevention strategy.

Psychological impact of COVID-19 pandemic and lockdown among the population involved in tourism sector in Lakeside of Pokhara: A qualitative study

Background and Aims

The COVID-19 pandemic has exerted a substantial influence on every sector of people's lives worldwide, including Nepal. The tourism industry is not exceptional. Lakeside Pokhara is one of the country's major tourist hubs and relies both on national and international visitors. The people residing in this area who depend on tourism-related businesses to regulate their daily living faced numerous stressors and psychological impacts due to the pandemic. This study aimed to explore the COVID-19 pandemic-related stressors and their psychological impact among people dependent on the tourism business in the Lakeside of Pokhara, located in the Gandaki Province of Nepal.

Method

Via the qualitative approach, semi-structured in-depth interviews were conducted to collect the data from 20 individuals related to tourism business stakeholders in Lakeside of Pokhara. Thematic analysis was performed to analyze the data.

Results

The study found business-related stressors among the people dependent on the tourism businesses, and these stressors were found to increase the experiences of psychological issues, including suicidal ideation. The pandemic has not only affected their economy but has also had an impact on their personal, familial, and social life. However, to combat the problems most of the study participants were found to be utilizing positive coping mechanisms, whereas some respondents were observed to consume more alcohol as a negative coping strategy.

Conclusions

People indulging in the tourism sectors were at greater risk of vulnerability in the future pandemic. Tourism business stakeholders struggled to combat the numerous stressors and psychological impacts carried out by the COVID-19 pandemic and lockdown. Therefore, there is a growing need for government bodies to implement favorable business-related policies, and Mental Health and Psychosocial Support (MHPSS) related programs to these stakeholders.

Mortality risk following self-harm in young people: a population cohort study using the Northern Ireland Registry of Self-Harm

BACKGROUND

Self-harm is a recognised predictor of suicide and is most common in those aged under 25 years. The aims of this study were to describe the characteristics of young people who present with self-harm; quantify the risk of suicide and other causes of death during follow up, and to identify factors associated with mortality risk.

METHODS

The Northern Ireland Registry of Self-Harm (NIRSH) is a national registry capturing complete data on all presentations made to the 12 Emergency Departments (EDs) in Northern Ireland (NI). Data relating to self-harm presentations registered in the NIRSH between 2012 and 2015 were linked to primary care registrations and death records up until 31st December 2018. Logistic regression was employed to examine the factors associated with self-harm. Cox regression was used to estimate mortality risk following self-harm and explore the associated risk factors.

RESULTS

The cohort consisted of 390,740 individuals aged 10-24 years registered with a General Practitioner (GP) in NI. During follow-up, 4,450 individuals presented with self-harm. Rates of self-harm were highest in females, those aged 20-24 years (ORadj  = 3.53, 95% CI 3.28-3.80, p < .001), and in the most deprived areas (ORadj  = 2.71, 95% CI 2.45-2.99, p < .001). Thirty five individuals who presented with self-harm died by suicide, accounting for 23% of all suicide deaths in the cohort. Suicide risk was increased 19-fold in those who presented with self-harm after adjustment for age, sex and area-level factors (HRadj  = 19.00, 95% CI 12.80-28.21, p < .001). Increased suicide risk was observed in males (HRadj  = 2.04, 95% CI 0.99-4.23, p = .05) and those using more violent methods of self-injury (HRadj  = 3.89, 95% CI 1.65-9.13, p < .001).

CONCLUSIONS

Young people who self-harm are at a significantly greater risk of suicide. Almost a quarter of young people who died by suicide in NI had presented to EDs with self-harm, highlighting that the ED may provide a nodal point of intervention among a typically hard to identify and reach population.

Widening the knowledge of non-employment as a risk factor for suicide: a Norwegian register-based population study

BACKGROUND

There is a known association between employment status and suicide risk. However, both reason for non-employment and the duration affects the relationship. These factors are investigated to a lesser extent. About one third of the Norwegian working age population are not currently employed. Due to the share size of this population even a small increase in suicide risk is of importance, and hence increased knowledge about this group is needed.

METHODS

We used discrete time event history analysis to examine the relationship between suicide risk and non-employment due to either unemployment or health-problems, and the duration of these non-employment periods. We analyze data from the Norwegian population registry from 2004 to 2014, which includes all Norwegian residents in the ages 19-58 born between 1952 and 1989. In total the data consists of 1 063 052 men and 1 024 238 women, and 2 039 suicides.

RESULTS

The suicide risk among the non-employed men and women is significantly higher than that of the employed. For the unemployed men, the suicide risk is significantly higher than the employed within the first 18 months. For the unemployed women we only find a significant association with suicide risk among those unemployed for six to twelve months. The suicide risk is especially increased among those with temporary health-related benefits. In the second year of health-related non-employment men have eightfold and women over twelvefold the OR for suicide, compared to the employed.

CONCLUSION

There is an association between non-employment and suicide risk. Compared to the employed both unemployed men and men and women with health-related non-employment have elevated suicide risk, and the duration of non-employment may be the driving force. Considering the large share of the working age population that are not employed, non-employment status should be considered in suicide risk assessment by health care professionals and welfare providers.

Cluster analysis to identify patient profiles and substance use patterns among pregnant persons with opioid use disorder

The study objective was to identify distinct profiles of pregnant persons with opioid use disorder (PP-OUD) using cluster analysis and examine difference in substance use patterns between profiles. We examined data from 104 PP-OUD ≤ 32 weeks of gestation who were recruited into a behavioral health clinical trial at two academic medical centers. We used Partitioning Around Medoids analysis to identify clusters and explored patterns of substance use and substance use treatment between clusters using bivariate statistical tests and regression methods. We identified two distinct clusters of participants, including 'Group A' (n = 68; 65.4 %) and 'Group B' (n = 36; 34.6 %). Group A had fewer members who were not employed (38 % vs 58 %) and incarcerated (3 % vs 8 %) compared to Group B. Group A compared with Group B included more members with: a history of overdose (72 % vs 50 %); anxiety (85 % vs 25 %); ≥moderate pain (76 % vs 22 %); ≥moderate depression (75 % vs 36 %); ≥moderate drug use severity (94 % vs 78 %); and, more days of cannabis (mean: 6.2 vs 2.3 days), stimulant (mean: 4.5 vs 1.3 days), and injection heroin (mean: 1.3 vs 0 days) use in the past 30 days (P < 0.05 for all comparisons). Clusters of PP-OUD differed with respect to sociodemographic characteristics, mental health conditions, and substance use patterns. More research is needed to confirm identified profiles and assess treatment outcomes associated with cluster membership.

The Effectiveness of Health-Oriented Interventions and Health Promotion for Unemployed People-A Meta-Analysis

Background: Unemployment is known to have negative effects on mental and physical health. Yet, the effectiveness of interventions aimed at improving the health of unemployed people is unclear. Methods: We conducted a random-effects meta-analysis of extant intervention studies with at least two measurement points and a control group. A literature search in PubMed, Scopus, and PsycINFO in December 2021 identified 34 eligible primary studies with 36 independent samples. Results: For mental health, the average meta-analytic effect sizes for the comparison of the intervention group and the control group were significant and of small size after the intervention, d = 0.22; 95% CI [0.08, 0.36], as well as at follow-up, d = 0.11; 95% CI [0.07, 0.16]. Effects on self-assessed physical health status were small and marginally significant (p = 0.10) after the intervention: d = 0.09; 95% CI [-0.02, 0.20], and insignificant at follow-up. However, when job search training was not part of the intervention program (i.e., all available resources were used solely for health promotion), the average effect size for physical health was significant after the intervention, d = 0.17; 95% CI [0.07, 0.27]. Furthermore, the effects of physical activity promotion were significant and of small-to-medium size after the intervention, leading to increased levels of activity, d = 0.30; 95% CI [0.13, 0.47]. Conclusions: Population-based health promotion programs are recommended because even measures with small effect sizes can actually improve the health of a large group of unemployed people.

Effects of social deprivation on risk factors for suicidal ideation and suicide attempts in commercially insured US youth and adults

We used US nationwide commercial insurance claims data (2011-2015) to study the effect of social deprivation on clinical and demographic risk factors for suicidal ideation (SI) and suicide attempts (SA) among US youth and adults < 65 years, after having a mental health or substance use disorder-related outpatient encounter. Neighborhood social deprivation level was summarized by the quintile of social deprivation index (SDI) at individuals' zip code level. Cox proportional hazard models were used to evaluate the effect of social deprivation on demographic and clinical risk factors for SI and SA. The study cohort consisted of 317,383 individuals < 65 years, with 124,424 aged < 25 (youth) and 192,959 aged between 25 and 64 (adults). Neighborhood social deprivation impacted risk factors for SI and SA differently for youth and adults. Among youth, SDI interacted with multiple risk factors for both SI and SA. The effects of the risk factors were larger on youth from middle socioeconomic neighborhoods. Among adults, risk of SI was the strongest in the most deprived neighborhoods, but risk of SA did not vary by neighborhood deprivation level. Our findings suggest community-based suicide prevention initiatives should be tailored according to neighborhood deprivation level and the targeted individual's age to maximize the impact.

Peer Intervention following Suicide-Related Emergency Department Presentation: Evaluation of the PAUSE Pilot Program

The risk for future suicidal behaviours is elevated following suicide attempts, particularly for those with complex needs or those who are disconnected from healthcare systems. The PAUSE program was designed to address this gap using peer workers to provide continuity and coordination of care following suicide-related emergency presentations. This study aimed to evaluate the pilot program's effect on suicidal ideation and hope, and to explore the acceptability and participants' experiences. A mixed-methods design was employed with pre- and post-evaluation questionnaires, including the GHQ-28-SS (general health questionnaire suicide scale), AHS (adult hope scale), and K10 (Kessler psychological distress scale). Participant engagement rates and semi-structured interviews were used to explore program acceptability. In total, 142 people were engaged with the PAUSE pilot between 24 August 2017 and 11 January 2020. There were no significant gender differences in engagement. The suicidal ideation scores decreased, and the hope scores increased after participation in PAUSE. A thematic analysis revealed that participants identified that the key program mechanisms were holistic and responsive support, ongoing social connectedness, and having peer workers who understood their experiences and treated them like people rather than clients. The small number of participants and lack of a control group limited the result generalizability. The findings suggest that PAUSE was an effective and acceptable model for supporting people following suicide-related hospitalisations in this pilot sample.

The importance of setting and therapeutic relationships when delivering chiropractic care to those living with disadvantage

BACKGROUND

Chiropractic is a mostly privatised health profession within Australia, with people experiencing disadvantage typically having limited access due to financial barriers. However, some universities within Australia offer community outreach clinics where students provide chiropractic care to people living with disadvantage. This demographic experiences higher rates of chronic conditions including musculoskeletal complaints and requires subsidisation to access privatised care. This need also offers opportunity for the chiropractic profession to work within community healthcare teams. A mixed-methods observational study was used to investigate how the unique setting of a student chiropractic community clinic may influence the experience and outcomes of those who attend.

METHODS

Three patient-reported outcome measures (PROMs) investigated client outcomes: Measure Yourself Medical Outcome Profile (MYMOP); European Five Domain Five Level Quality of Life Questionnaire (EQ-5D-5L); and the Patient Enablement Instrument. The PROMs data were analysed descriptively and inferentially. Interviews were conducted with clients who had received chiropractic care, chiropractic students, clinical supervisors and staff of the centre. Interview data were coded using thematic analysis, and themes were formed using Bronfenbrenner's socio-ecological systems framework and non-participant observations.

RESULTS

Thirty-seven participants completed baseline PROMs and 17 completed follow-ups after four treatments. Seventy-two percent of participants nominated their primary complaint as chronic. Significant change was noted in general health and wellbeing for the MYMOP, pain and disability for the EQ-5D-5L and index scores for the EQ-5D-5L suggested improved health and wellbeing. Most clients experienced higher levels of enablement post treatment. Twelve participants were interviewed (four were clients), with five themes emerging from the interview data. Clients reported their lived experiences impacted their health problems and attending the clinic offered benefits beyond improvement of pain and disability.

CONCLUSIONS

Interview data suggested that these benefits were due to a combination of therapy, the setting and the relationships formed within that setting. Complementing this, PROM data suggested clients experienced better levels of health and wellbeing and decreased levels of pain and disability. Findings indicated that people who experienced disadvantage may receive broader benefits from attending community centres offering chiropractic care. Services such as chiropractic may be complementary in meeting the healthcare needs of those experiencing disadvantage.

Suicide among young-old and old-old adults in rural China: A case-control psychological autopsy study

OBJECTIVE

Late-life suicide is a vital public health concern. Though gerontological research suggested the young-old and old-old phases were heterogeneous, age differences in the elderly suicide have not been well studied due to the lack of comparable control groups and small samples. The study aimed to examine the age-specific suicidal characteristics and risk factors among the young-old (60-79) and old-old (over 80) elderly.

METHODS

Two hundred and forty two suicide decedents and 242 living comparisons were enrolled in a 1:1 matched case-control psychological autopsy study in rural China: 173 young-old and 69 old-old in each group. Suicidal characteristics, demographic characteristics, living arrangements, physical health, mental disorder, and psychosocial factors were collected. We used logistic regression models to assess risk factors of suicide and test for interactions between age and each risk factor.

RESULTS

Pesticide suicide was more prevalent among young-old suicides than old-old suicides (56.07% vs. 40.58%, p = 0.029). Non-currently married, unemployment, mental disorder, higher disability in physical activities of daily living, higher hopelessness and higher depressive symptom were significantly associated with suicide among older adults. The effect of poor function in physical activities of daily living on suicide was significantly greater during younger ages (p for interaction = 0.038).

CONCLUSIONS

Findings indicated that most suicidal characteristics and risk factors for completed suicide were generally similar among young-old and old-old adults. But poor function in physical activities of daily living predicted increase suicide risk only at younger ages. In addition to common risk factors, age-specific factors should also be noted in suicide prevention.

CLINICAL TRIAL REGISTRATION

According to the ICMJE, purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) will not require registration. Our study was not registered because this is a case-control study. But all procedures of the study were carried out in accordance with the latest version of the Declaration of Helsinki. The study were approved by the Institutional Review Boards of the Central South University, Shandong University, and Guangxi Medical University.

Sleep Quality and Mental Health Consequences of COVID-19 Pandemic in the Aviation Community in Greece

OBJECTIVE

The aim of this study was to assess the mental health and sleep quality of aviation workers in Greece during the pandemic.

METHODS

A cross-sectional study of aviation workers in Greece was conducted.

RESULTS

Sleep disturbances were observed in 25.4% of our 548 participants, whereas 8.2% and 5.8% reported at least mild depressive and anxiety symptoms, respectively. The impact of the pandemic on their mental health was their primary concern, which increased for many active pilots according to their workload. Those infected mainly faced daily tiredness and fatigue. Smoking habits and high body mass index were a predisposition for more physical symptoms. Cabin crew and women generally yielded worse scores than the other groups.

CONCLUSION

Fear of infection could explain mental health issues, whereas physical symptoms of those infected could be attributed to long-COVID (coronavirus disease) syndrome. Flight attendants' lower ratings may be due to more occupational exposure.

The Role of Unemployment, Financial Hardship, and Economic Recession on Suicidal Behaviors and Interventions to Mitigate Their Impact: A Review

Understanding the social determinants and risk factors for suicidal behaviors underlies the development of effective suicide prevention interventions. This review focused on recently published literature (2010 onwards), with the aim to determine the role of economic factors (at the individual and population level) on suicidal behaviors and ideation as well as the effectiveness of interventions addressing these factors in reducing suicidal behaviors and ideation. Where available, literature examining the economic impact of COVID-19 was highlighted. Economic recession and unemployment are associated with increased risk of suicidal behavior at the population and individual level. Additionally, personal financial problems such as debt and financial strain are associated with increased risk of suicidal behavior and ideation at the individual level. Regarding interventions, unemployment benefits, employment protection legislation, higher minimum wage and active labor market programs may reduce suicide at the population level. However, it is not clear what impact they have at the individual level, nor in relation to suicide attempts, self-harm, or suicidal ideation. There was a lack of evidence as to the effectiveness of financially focused suicide prevention interventions at either level. Current findings were contextualized within, and advance, prominent social theoretical models. Recommendations focused on future areas of research, including the unfolding economic impact of COVID-19, as well as the co-design and evaluation of tailored interventions and/or gatekeeper training for those in the financial and welfare sector, and enhanced early education aimed at increasing financial literacy in young people before onset or exacerbation of financial hardship.

The relationship between employment and health for people from refugee and asylum-seeking backgrounds: A systematic review of quantitative studies

Background

For the general population, the positive effects of paid employment on health and wellbeing are well established. However, less is known for people from refugee and asylum-seeking backgrounds. This review aims to systematically summarise the quantitative literature on the relationship between employment and health and wellbeing for refugees and asylum seekers.

Method

A search strategy was conducted in online databases, including MEDLINE, PsychINFO, EMCARE, SCOPUS, CINHAL, ProQuest and Web of Science. Articles were screened against inclusion and exclusion criteria. Studies published in English between 2000 to October 2021 were included if they used quantitative methods to consider the relationship between employment and health for refugees and asylum seekers in resettlement countries. Study quality was assessed using The Joanna Briggs Institute's Critical Appraisal Tools. Findings were synthesised using a narrative approach.

Results

Seventy-two papers were identified. The majority of papers (N = 58, 81%) examined the association between employment and mental health outcomes. Overall, while there were inconsistencies in the findings, employment had a positive effect on mental health particularly in reducing levels of psychological distress and depression. Though more limited in number, the papers examining physical health suggest that people who are employed tend to have better physical health than unemployed persons. There was some evidence to support the bi-directional relationship between employment and health. Poor mental and physical health negatively impacted the odds of employment and occupational status of refugees.

Conclusion

Good quality employment is an essential component of refugee resettlement and this review found that in general employment is also beneficial for refugee health, particularly aspects of mental health. More research regarding the effects of employment on physical health is required. The effects of refugee-specific factors such as gender roles, torture, and trauma on the relationship between employment and health also require further investigation.

Psychological distress and suicidal ideation among male construction workers in the United States

BACKGROUND

Male workers in the US construction industry have a higher suicide rate than other workers in the nation. However, related research on this population remains sparse. This study evaluated psychological distress and suicidal ideation in these workers, and possible underlying factors.

METHODS

Data from the National Survey of Drug Use and Health from 2008 to 2014 were analyzed. Stratified and multiple logistic regression analyses were conducted to examine factors associated with psychological distress and suicidal ideation among male construction workers aged ≥18 years (n = 12,034).

RESULTS

Nearly one-third (29.6%) of male construction workers in the United States experienced psychological distress (23.8% graded as moderate, 5.8% as severe), and 2.5% reported suicidal ideation in the past year. Higher odds of serious psychological distress and suicidal ideation were found among workers who were younger, worked part-time, missed workdays due to injury or illness, or were in poor health. Illicit opioid use (odds ratio [OR] = 1.87, 95% confidence interval [CI]: 1.22-2.89) and alcohol dependence or abuse (OR = 2.64, 95% CI: 1.74-3.99) significantly escalated the odds of suicidal ideation. The odds of suicidal ideation among workers with serious psychological distress were 33 times higher than those having no or minor psychological distress (OR = 32.91, 95% CI: 19.82-54.65) when other factors were constant.

CONCLUSIONS

Occupational and nonoccupational factors were associated with constructionworkers' psychological distress and suicidal ideation. Both illicit opioid use and alcohol dependence or abuse were risk factors, and psychological distress was a strong predictor for suicidal ideation. To improve workers' mental health, it is necessary to integrate workplace injury prevention with illicit opioid-use reduction programs and suicide prevention.

Current Unemployment, Unemployment History, and Mental Health: A Fixed-Effects Model Approach

Poor mental health among the unemployed-the long-term unemployed in particular-is established, but these associations may be driven by confounding from unobserved, time-invariant characteristics such as past experiences and personality. Using longitudinal register data on 2,720,431 residents aged 30-60 years, we assessed how current unemployment and unemployment history predict visits to specialized care due to psychiatric conditions and self-harm in Finland in 2008-2018. We used linear ordinary-least-squares and fixed-effects models. Prior to adjusting for time-invariant characteristics, current unemployment was associated with poor mental health, and the risk increased with longer unemployment histories. Accounting for all time-invariant characteristics with the fixed-effects models, these associations attenuated by approximately 70%, yet current unemployment was still associated with a 0.51 (95% confidence interval: 0.48, 0.53) percentage-point increase in the probability of poor mental health among men and women. Longer unemployment histories increased the probability among men in their 30s but not among older men or among women. The results indicate that selection by stable characteristics may explain a major part of the worse mental health among the unemployed and especially the long-term unemployed. However, even when controlling for this selection, current unemployment remains associated with mental health.

A decline in Australian suicide during COVID-19? A reflection on the 2020 cause of death statistics in the context of long-term trends

This correspondence considers the overall decline in suicide in 2020 in the context of longer-term sex and age-specific trends over the period 1907–2020. When considering suicide rates from the beginning of the 20th century, the decrease in the total suicide rate from 2019 to 2020 is less noteworthy.

Domains of Psychosocial Risk Factors Affecting Young Construction Workers: A Systematic Review

Despite being a key provider of employment, construction work significantly contributes to poor mental health among young construction workers worldwide. Although there are studies on the psychosocial risk factors (PRFs) that make young construction workers susceptible to poor mental health, the literature is fragmented. This has obscured a deeper understanding of PRFs and the direction for future research, thus making it challenging to develop appropriate interventions. To address this challenge, we systematically reviewed the literature on young construction workers’ PRFs using meta-aggregation, guided by the PICo, PEO, and PRISMA frameworks. We sought to synthesize the domains of PRFs that affect young construction workers’ mental health, and to determine the relationships between the PRF domains, psychological distress, and poor mental health. A total of 235 studies were retrieved and 31 studies published between 1993 and 2020 met the inclusion criteria. We identified 30 PRFs and categorized them into ten domains, which were further classified into personal, socio-economic, and organizational/industrial factors. The findings of this review contribute to achieving an in-depth understanding of young construction workers’ PRF domains and their patterns of interaction. The findings are also useful to researchers and policymakers for identifying PRFs that are in critical need of attention.

Increase in Mental Disorders During the COVID-19 Pandemic-The Role of Occupational and Financial Strains

BACKGROUND

Numerous studies have reported an increase in mental disorders during the COVID-19 pandemic, but the exact reasons for this development are not well understood. In this study we investigate whether pandemic-related occupational and financial changes (e.g., reduced working hours, working from home, financial losses) were associated with increased symptoms of depression and anxiety compared with the situation before the pandemic.

METHODS

We analyzed data from the German National Cohort (NAKO) Study. Between May and November 2020, 161 849 study participants answered questions on their mental state and social circumstances. Their responses were compared with data from the baseline survey before the pandemic (2014-2019). Linear fixed-effects models were used to determine whether individual changes in the severity of symptoms of depression (PHQ-9) or anxiety (GAD-7) were associated with occupational/ financial changes (controlling for various covariates).

RESULTS

The prevalence of moderate or severe symptoms of depression and anxiety increased by 2.4% and 1.5%, respectively, during the COVID-19 pandemic compared with the preceding years. The mean severity of the symptoms rose slightly. A pronounced increase in symptoms was observed among those who became unemployed during the pandemic (+ 1.16 points on the depression scale, 95% confidence interval [0.91; 1.41], range 0-27). Increases were also seen for reduced working hours with no short-time allowance, increased working hours, working from home, insecurity regarding employment, and financial strain. The deterioration in mental health was largely statistically explained by the occupational and financial changes investigated in the model.

CONCLUSION

Depressive symptoms and anxiety disorders increased slightly in the study population during the first year of the COVID-19 pandemic. Occupational and financial difficulties were an essential contributory factor. These strains should be taken into account both in the care of individual patients and in the planning of targeted prevention measures.

Prospective association between receipt of the economic impact payment and mental health outcomes

BACKGROUND

The Coronavirus Aid, Relief, and Economic Security Act of 2020 provided 'economic impact payments' (EIPs) of $1200 to US adults with annual personal income of $75 000 or less. This study examined the prospective association between EIP receipt and mental health outcomes.

METHODS

A nationally representative sample of 3169 middle-income and low-income US adults completed a baseline assessment of their health and well-being in May-June 2020 and a 3-month follow-up assessment during the period of the COVID-19 pandemic when EIPs were distributed.

RESULTS

Controlling for sociodemographic characteristics, EIP recipients had higher odds of reporting a positive COVID-19 test, endorsing a history of post-traumatic stress disorder and reporting any illicit drug use in the past month than participants who did not receive EIP. Participants who did not receive EIP were more likely to report a history of anxiety disorder or alcohol use disorder and recent suicidal ideation than EIP recipients. There was no association between EIP receipt and financial distress, although over one-third to over half of EIP recipients were not employed at baseline. Between baseline and 3-month follow-up, receipt of EIP was significantly associated with reduced medical conditions and alcohol use problems, but increased depression, suicidal ideation and COVID-19 era-related stress.

CONCLUSION

The EIP provided a brief income stimulus to many adults in need but was not associated with improvements in financial distress or mental health among middle-income and low-income recipients. Long-term income security and employment may be more important to improving and sustaining positive mental health outcomes.

A time-series analysis of the association between alcohol and suicide in Australia

INTRODUCTION

800,000 people die by suicide every year according to World Health Organisation data. Studies have shown associations between alcohol consumption and suicide, with most demonstrating that alcohol consumption increases suicide risk. However, some studies from high consumption countries show results in the opposite direction. This present study examines the association between per capita (PC) alcohol consumption and same year suicide mortality in Australia, and tests for lag effects, between 1910 and 2017.

MATERIALS AND METHODS

Age and gender-specific autoregressive integrated moving average (ARIMA) models were used to examine associations between alcohol consumption PC and suicide mortality rates. Associations between unemployment, divorce, barbiturates access, and the Great Depression and World War II, and suicide were examined.

RESULTS

A 10% increase in PC alcohol consumption was associated with a 5% and 5.1% decrease in overall and male suicide mortality respectively in the same year. However, a 10% increase in PC alcohol consumption was associated with an 5.1% and 5.4% increase in overall and male suicide mortality respectively 12 years later. This association differed among age groups and was significant in the male population only. Unemployment, divorce, the Great Depression and WW2, and barbiturates access were significantly associated with same year suicide mortality.

DISCUSSION

Contemporaneous alcohol consumption was associated with decreased suicide mortality, but was also associated with an increased risk of suicide 12 years later. Unemployment and barbiturates access were associated with an increased risk of suicide. Interventions and policies that address chronic alcohol consumption and support the unemployed may reduce suicide mortality.

Outcomes from the medication assisted treatment pilot program for adults with opioid use disorders in rural Colorado

BACKGROUND

As Colorado ranked among the top nationally in non-medical use of opioids, a pilot medication for opioid use disorder (MOUD) program was developed to increase the number of NPs and PAs providing MOUD in order to bring this evidence- based treatment to 2 counties showing disproportionally high opioid overdose deaths. Over the first 18 months, the MOUD Pilot Program led to 15 new health care providers receiving MOUD waiver training and 1005 patients receiving MOUD from the 3 participating organizations. Here we evaluate patient centered clinical and functional outcomes of the pilot MOUD program implemented in 2 rural counties severely affected by the opioid crisis.

METHODS

Under state-funded law (Colorado Senate Bill 17-074), three rural agencies submitted de-identified patient-level data at baseline (N = 1005) and after 6 months of treatment (N = 190, 25%) between December 2017 and January 2020. The Addiction Severity Index, PhQ9 and GAD-7 with McNemar-Bowker, and Wilcoxon Signed Rank tests analysis were used to measure patient outcomes across after participation in the program. .

RESULTS

Patients in treatment reported using less heroin (52.1% vs 20.4%), opioids (22.3% vs 11.0%), and alcohol (28.6% vs 13.1%, all P < 0.01). Patients reported improved health (53.4% vs. 68.2%, P = 0.04), less frequency of disability (8.69 vs. 6.51, P = 0.02), symptoms (29.8% vs 21.3%), pain (67.5% to 53.6), worry (45.3% vs 62.3%), anxiety (49.7% vs 23.2%), depression (54.1% vs 23.3%, all P < 0.02) after treatment.

CONCLUSIONS

This study shows decreased substance use, improved physical and mental health, and reduced symptoms after 6 months of MOUD. Although more research on retention and long-term effects is needed, data shows improved health outcomes after 6 months of MOUD. Lessons learned from implementing this pilot program informed program expansion into other rural areas in need to address some of Colorado' major public health crises.

Suicidal Histories in Adults Experiencing Psychological Trauma: Exploring Vulnerability and Protective Factors

OBJECTIVE

This study aimed to identify vulnerability and protective factors for suicidal histories among adults experiencing psychological trauma.

METHOD

Adults seeking treatment for psychological trauma (N = 113) completed self-report questionnaires measuring childhood trauma history, self-concept, relational functioning, emotion regulation, living arrangements, employment status, marital status, and suicidal history. Independent samples t-tests were used to determine variables on which those with and without suicidal histories differed significantly. These variables were then entered into a binary logistic regression model to identify factors which independently distinguished between those with and without a suicidal history.

RESULTS

Univariate differences were found for childhood emotional abuse (CEA), childhood emotional neglect (CEN), emotion deactivation, and employment status, with those in the suicidal history group scoring higher on all of these. CEA (OR = 1.13, 95% CI = 1.01-1.27) and employment status (OR = 4.12, 95% CI = 1.23-13.73) remained significant predictors of suicidal status in the multivariable logistic regression.

CONCLUSIONS

CEA was an independent vulnerability factor for suicidal risk, highlighting the need for clinicians to assess exposure to such trauma in those presenting with proximal traumatic experiences. Being in employment was an independent protective factor against suicidal risk, highlighting the importance of social buffers or networks when faced with traumatic situations.

The Association Between Employment Status and Mental Health in Young Adults: A Nationwide Population-Based Study in Korea

BACKGROUND

There has been limited evidence on the association between employment status and mental health among young adults. Therefore, this study investigated the association between employment status and mental health in Korean young adults.

METHODS

Data from 15,649 adults aged 19-39 years who participated in the Korea National Health and Nutrition Examination Survey (2007-2013, 2015, and 2017) were analyzed. Employment status was categorized by those who worked in paid jobs or those who did unpaid work for relatives. Mental health problems included depressive mood and suicide ideation. We performed a multiple logistic regression analysis.

RESULTS

Of the participants, 33.5% were unemployed. The odds ratio (OR) of depressive mood (1.28, 95% CI: 1.06-1.55) was higher in unemployed 20-year-olds than employed ones and ORs of suicide ideation were higher among unemployed males (1.59, 1.16-2.20) and 30-year-olds (1.38, 1.13-1.70) than employed ones, respectively. Further, compared to employed males, the ORs of depressive mood (3.10, 2.54-3.77) and suicide ideation (4.44, 3.57-5.53) were the highest among unemployed females.

LIMITATIONS

This study could not explain the causal relationship between employment status and mental health because it was a cross-sectional study. We did not include the relationship between mental health and employment status before the last week.

CONCLUSIONS

Among young adults, unemployed status was significantly associated with an increased risk of mental health problems such as depressive mood and suicide ideation. Multifaceted efforts are required to reduce these mental health issues among unemployed young adults.

Why adults with psychiatric conditions request euthanasia: A qualitative interview study of life experiences, motives and preventive factors

OBJECTIVE

As the empirical picture of adults with psychiatric conditions (further referred to as 'patients') requesting euthanasia is still incomplete, this study aims to deepen our understanding of why these patients request euthanasia, how this relates to the option of suicide, and what could have prevented these patients from considering death and requesting euthanasia.

METHODS

A qualitative study using in-depth, face-to-face interviews was conducted with 16 patients who had their euthanasia request under assessment in the period 2016-2020. Thematic coding was used.

FINDINGS

Most patients were in a state of feeling emotionally worn-out as a result of the many accumulated misfortunes and setbacks, leading to the all-pervasive sense that life is no longer worth living. Whereas some patients reported lifelong adversity, others struggled predominantly in later life. Whereas some patients longed for death strongly, others expressed ambivalence towards death ideation, and some even requested euthanasia to hear of their ineligibility for it, to restore hope and to (re)find meaning in life. patients valued euthanasia over suicide as being more dignified and acceptable, both for themselves and for their inner circle. With regard to preventive factors, patients posited the need for improved accessibility and quality of mental healthcare, as well as a profound change in society's perception of, and support for, these patients.

CONCLUSIONS

This study revealed the many complexities of euthanasia in the context of psychiatry, due to the many differences in patients' background characteristics, in their motives for requesting euthanasia, and the multi-layered aspects of mental suffering that go beyond the field of psychiatry.

National or population level interventions addressing the social determinants of mental health - an umbrella review

Background

Social circumstances in which people live and work impact the population’s mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198).

Results

We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk.

Conclusion

This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12145-1.

COVID-19 Associated Suicidal Ideation in Older Adults: Two Case Reports With a Review of the Literature

The COVID-19 pandemic may profoundly harm the mental health and emotional well- being of many older adults. Public health interventions to minimize the spread of the virus have had the unintended consequences of worsening social isolation, financial stress, and unemployment. Results of early research efforts assessing the impact of these interventions on the mental health of older adults have been mixed. Available findings suggest that a subset of community-dwelling older adults have been less negatively impacted than younger adults, while people of color, the poor, residents of nursing homes and other communal living environments, and those living with dementia and their caregivers are more likely to suffer from COVID-related health problems. This manuscript describes two older adults for whom COVID-19 associated stresses caused significant worsening in their psychiatric illnesses, including the emergence of suicidal ideation, summarizes the literature on the impact of interactions between psychosocial stresses and biological factors on the mental health and well-being of older adults, and discusses interventions to help older adults whose mental health has worsened due to COVID-19. Timely and accurate diagnosis, prompt provision of individualized care using both pharmacologic and psychotherapeutic interventions, adoption of new technologies that permit care to be provided safely at a distance and which allow for virtual social interactions, coupled with ongoing advocacy for policy changes that address significant health care disparities and provide older adults continued access to health care and relief from financial hardship, will help older adults remaining as healthy as possible during the pandemic.

What helps the unemployed to stay healthy? A qualitative study of coping with the negative effects of job loss

Background: A variety of empirical studies have shown the negative effects of unemployment on health. A research gap exists regarding salutogenic factors and successful coping strategies to master involuntary job loss and unemployment with the least damage to health. Hence, this study aims at generating a deeper understanding of coping with unemployment and maintaining health.

Design and methods: We conducted problem-centered guideline interviews with 21 unemployed people. For the analysis of the interviews, we followed the qualitative content analysis.

Results: The study identified that five themes were particularly relevant in coping with unemployment: i) the financial situation, ii) social support and psychosocial strains due family obligations, iii) health problems, iv) time structure, and v) coping strategies. The respondents expressed their financial situation as a major strain in unemployment. They emphasized the importance of social support by their families, but reported also stressful psychosocial demands due to their family members. Further, our respondents mentioned their health problems as a barrier to reintegration into the labour market. In connection with social role demands, a rudimentary time structure was reported by the participants. The common reported coping strategy in unemployment is seeking social support.

Conclusions: In summary, our results show – besides health problems and a deteriorated financial situation in unemployment – the great importance of social support and time structure for maintaining mental health in unemployment. Consequently, health promotion approaches for the unemployed should especially target social support and time structure.

The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management

The clinical construct of "anxiety neurosis" was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM-III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive-behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

Which is most important for mental health: Money, poverty, or paid work? A fixed-effects analysis of the UK Household Longitudinal Study

BACKGROUND

The relative importance of income, poverty and unemployment status for mental health is unclear, and understanding this has implications for income and welfare policy design. We aimed to assess the association between changes in these exposures and mental health.

METHODS

We measured effects of three transition exposures between waves of the UK Household Longitudinal Study from 2010/11-2019/20 (n=38,697, obs=173,859): income decreases/increases, moving in/out of poverty, and job losses/gains. The outcome was General Health Questionnaire (GHQ), which measures likelihood of common mental disorder (CMD) as a continuous (GHQ-36) and binary measure (score ≥4 = case). We used fixed-effects linear and linear probability models to adjust for time invariant and time-varying confounders. To investigate effect modification, we stratified analyses by age, sex and highest education.

RESULTS

A 10% income decrease/increase was associated with a 0.02% increase (95% CI 0.00, 0.04) and 0.01% reduction (95% CI -0.03, 0.02) in likelihood of CMD respectively. Effect sizes were larger for moving into poverty (+1.8% [0.2, 3.5]), out of poverty (-1.8%, [-3.2, -0.3]), job loss (+15.8%, [13.6, 18.0]) and job gain (-11.4%, [-14.4, -8.4]). The effect of new poverty was greater for women (+2.3% [0.8, 3.9] versus +1.2% [-1.1, 3.5] for men) but the opposite was true for job loss (+17.8% [14.4, 21.2] for men versus +13.5% [9.8, 17.2] for women). There were no clear differences by age, but those with least education experienced the largest effects from poverty transitions, especially moving out of poverty (-2.9%, [-5.7, -0.0]).

CONCLUSIONS

Moving into unemployment was most strongly associated with CMD, with poverty also important but income effects generally much smaller. Men appear most sensitive to employment transitions, but poverty may have larger impacts on women and those with least education. As the COVID-19 pandemic recedes, minimising unemployment as well as poverty is crucial for population mental health.

Unemployment associated with major depression disorder and depressive symptoms: a systematic review and meta-analysis

Objectives. This study investigated the association between unemployment and depressive symptoms and major depression disorder worldwide using a systematic review and meta-analysis. Methods. Search time was limited to all articles published in English until December 2020. In the association between unemployment and depression, first, the results of qualified studies were extracted and, then, the results of each study were pooled with each other using the random effects method. Results. The prevalence of depression in the unemployed is 21%, 95% confidence interval (CI) [18, 24%]. This prevalence for depression symptoms is 24%, 95% CI [20, 28%] and for major depressive disorder is 16%, 95% CI [9-24%]. The association between unemployment and depressive symptoms was odds ratio (OR) 2.06, 95% CI [1.85, 2.30] and the association for major depressive disorder was OR 1.88, 95% CI [1.57, 2.25]. The association between unemployment and depression in men was OR 2.27, 95% CI [1.76, 2.93] and in women was OR 1.62, 95% CI [1.40, 1.87]. Conclusions. What is clear from the present study is that unemployment can lead to a higher prevalence of depressive symptoms and major depressive disorder, thereby undermining the mental health of the unemployed.

Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span

Importance

Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span.

Objective

To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population.

Design, Setting, and Participants

Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021.

Main Outcomes and Measures

For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity.

Results

The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up.

Conclusions and Relevance

In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

The impact of COVID-19 on different population subgroups: ethnic, gender and age-related disadvantage

Against a background of stalling UK life expectancy, the COVID-19 pandemic is a major crisis for public health with impacts differing markedly by ethnicity, gender, and age. Direct health impacts include mortality and long-term harms among survivors. Social disruption and lockdown measures arising from uncontrolled infection have destabilised healthcare and other essential services. The economic crisis resulting from the pandemic is already triggering job losses, which will in turn have their own adverse health effects. These myriad impacts of the pandemic are not affecting everyone equally. Ethnic minorities, men and older people have disproportionately suffered from COVID-19, including their risk of mortality. However, some indirect impacts - including those on mental health and employment - are more likely to affect women and younger people. The health consequences of the pandemic will affect the lives of people in the UK for decades.

Men's Dropout From Mental Health Services: Results From a Survey of Australian Men Across the Life Span

While increasing numbers of Australian men are accessing mental health services, the sustainability of their therapy engagement varies significantly, with many men being lost to follow-up. The current study investigated dropout rates in a large community-based male sample to highlight the reasons for, and potential predictors of, men dropping out of mental health care services. Data were drawn from an online survey of 1907 Australian men (aged 16–85; M = 44.1 years) reflecting on their broad experiences in mental health therapy. Participants responded to bespoke items assessing their past dropout experience and reasons for dropping out, the odds of which were modeled in relation to demographics and predictors (e.g., therapist engagement strategies, alignment to traditional masculinity and pre-therapy feelings of optimism, shame, and emasculation). The overall dropout rate from therapy was 44.8% (n = 855), of which 26.6% (n = 120) accessed therapy once and did not return. The most common reasons for dropout were lack of connection with the therapist (54.9%) and the sense that therapy lacked progress (20.2%). Younger age, unemployment, self-reported identification with traditional masculinity, the presence of specific therapist engagement strategies, and whether therapy made participants feel emasculated all predicted dropout. Current depressive symptoms and suicidality were also higher amongst dropouts. Therapists should aim to have an honest discussion with all clients about the importance of therapy fit, including the real likelihood of dropout, in order to ensure this does not deter future engagement with professional services.

Recession and risk of suicide in Denmark during the 2009 global financial crisis: an ecological register-based study

AIM

The aim of this study is to analyse the potential impact from the financial crisis (onset in 2009) on suicide rates in Denmark. The hypothesis is that the global financial crisis raised unemployment which leads to raising the suicide rate in Denmark and that the impact is most prominent in men.

METHOD

This study used an ecological study design, including register data from 2001 until 2016 on unemployment, suicide, gender and calendar time which was analysed using Poisson regression models and interrupted time series analysis.

RESULTS

The correlation between unemployment and suicide rates was positive in the period and statistically significant for all, but at a moderate level. A dichotomised version of time (calendar year) showed a significant reduction in the suicide rate for women (incidence rate ratio 0.87, P=0.002). Interrupted time series analysis showed a significant decreasing trend for the overall suicide rate and for men in the pre-recession period, which in both cases stagnated after the onset of recession in 2009. The difference between the genders' suicide rate changed significantly at the onset of recession, as the rate for men increased and the rate for women decreased.

DISCUSSION

The Danish social welfare model might have prevented social disintegration and suicide among unemployed, and suicide prevention programmes might have prevented deaths among unemployed and mentally ill individuals.

CONCLUSIONS

We found some indications for gender-specific differences from the impact of the financial crises on the suicide rate. We recommend that men should be specifically targeted for appropriate prevention programmes during periods of economic downturn.

COVID-19 and Suicide: A Deadly Association

ABSTRACT

COVID-19 hit the world amidst an unprecedented suicide epidemic in this century. As the world focuses on limiting the spread of the virus and prioritizing acutely medically ill patients, containment measures are not without mental health consequences. With rising anxiety and depression, risk of suicide-acutely and in the aftermath of the pandemic-also rises. This article aims to shed light on this major public health problem and better understand what factors may create or exacerbate psychiatric symptoms and suicide. We review suicide data predating the pandemic and examine impact of previous epidemics on suicide rates. We then focus on the current pandemic's impacts and the world's response to COVID-19. We examine how these may lead to increased suicide rates, focusing on the US population. Finally, we offer suggestions on mitigating interventions to curb the impending rise in suicide and the resultant increased burden on an already stretched health care system.

Gendered experiences of unemployment, suicide and self-harm: a population-level record linkage study

BACKGROUND

Unemployment and being not in the labour force (NILF) are risk factors for suicide, but their association with self-harm is unclear, and there is continuing debate about the role of confounding by prior mental health conditions. We examine associations between employment status and self-harm and suicide in a prospective cohort, taking into account prior mental-health-related factors.

METHODS

We used linked data from the New Zealand Integrated Data Infrastructure. The outcomes were chosen to be hospital presentation for self-harm and death by suicide. The exposure was employment status, defined as employed, unemployed, or NILF, measured at the 2013 Census. Confounders included demographic factors and mental health history (use of antidepressant medication, use of mental health services, and prior self-harm). Logistic regression was used to model effects. Analyses were stratified by gender.

RESULTS

For males, unemployment was associated with an increased risk of suicide [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.20-1.84] and self-harm (OR: 1.55, 95% CI: 1.45-1.68) after full adjustment for confounders. NILF was associated with an increased risk of self-harm (OR: 1.43, 95% CI: 1.32-1.55), but less of an association was seen with suicide (OR: 1.19, 95% CI: 0.94-1.49). For females, unemployment was associated with an increased risk of suicide (OR: 1.30, 95% CI: 0.93-1.80) and of self-harm (OR: 1.52, 95% CI: 1.43-1.62), and NILF was associated with a similar increase in risk for suicide (OR: 1.31, 95% CI: 0.98-1.75) and self-harm (OR: 1.32, 95% CI: 1.26-1.40).

DISCUSSION

Exclusion from employment is associated with a considerably heightened risk of suicide and self-harm for both men and women, even among those without prior mental health problems.