Interventions to reduce the impact of unemployment and economic hardship on mental health in the general population: a systematic review

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

Impact of employment and income support interventions on the health of young adults with episodic disability: Findings from a systematic review

OBJECTIVE

Young adults living with episodic disabilities face unpredictable disruptions to their employment and health. Our study aimed to examine the impact of employment and income support interventions on the health and well-being of young adults living with episodic disabilities.

METHODS

We conducted a systematic review of peer-reviewed intervention studies published in 2001-2021 in industrialized contexts. Two independent reviewers screened titles, abstracts and full-texts. We undertook a narrative synthesis of eligible articles.

RESULTS

Our search yielded 15 269 published articles, of which only five studies were eligible for evidence synthesis. All articles were appraised as being of medium quality. Four interventions focused on young adults living with mental health conditions. Two were based in clinical settings; three were based in community-based settings. Each employment intervention exhibited improvements in health outcomes. Three studies examined the impact of supported employment interventions that were particularly beneficial to improving work and health outcomes.

CONCLUSION

Involvement in employment interventions could provide benefits for the health of young adults living with episodic disabilities. Our systematic review highlights the need for research to elaborate on the ways in which employment interventions can impact the health and well-being of young adults living with different episodic disabilities.

The risk of suicidal intention in severe mental illness: An ecological perspective

OBJECTIVE

Guided by the ecosystem theory model framework, we aimed to explore the influence of three ecological dimensions (social, family and psychological factors) on suicidal intention in people with severe mental illness (SMI). We hypothesized that three factors influence suicidal intention, and that psychological factors may play a mediating role in the influence of social and family factors on suicidal intention.

METHODS

We collected 994 patients with SMI aged 18 and above from May 2021 to March 2022 in the Fourth Hospital of Fuzhou City. We used logistic regression to analyse the association between social, family, psychological factors and suicidal intention. Furthermore, we explored the mediating effects among the influencing factors.

RESULTS

Younger male patients with schizophrenia were more likely to have suicidal intention due to psychosocial family factors (p < .05). Social factors (poor interpersonal relations, social retreat, social activities outside the home), family factors (parental functions, activities within the family, family functions), psychological factors (anxiety, depression, interest in the outside world, overt aggression, lack of accountability and planning) were all independent risk factors for suicidal intention in patients. Mediation analysis showed anxiety and depression mediated the role of social and family factors on suicidal intention (p < .05).

CONCLUSION

Social, family and psychological factors were important risk factors for suicidal intention, with anxiety and depression being partial mediators for suicidal intention. Therefore, interventions that enhance family and social functioning and reduce anxiety and depression may be effective in reducing suicidal intention in SMI.

Food insecurity, mental health and in-hospital mortality following the COVID-19 pandemic in a socially deprived UK coastal town

BACKGROUND

Public health interventions are essential to prevent a long tail of costly, avoidable and worsening ill health in coastal communities following the COVID-19 pandemic, yet no research exists to guide policy and practice as to which groups within coastal communities are vulnerable and most in need of such interventions. Within this aim, we explore engrained and emerging vulnerabilities of food insecurity, health and well-being for different demographic groups within the deprived coastal community of Fleetwood, Lancashire, UK, before and after the pandemic.

METHODS

Routinely collected data of free school meal eligibility, community mental health referrals and hospital admissions between 28 March 2016 and 31 December 2021 were aggregated by locality and deprivation within Fleetwood. Temporal autoregressive models, generalised linear mixed models and survival analyses were employed to compare trends and associations in food insecurity, health and well-being indicators against deprivation indices, demographics, comorbidities (including COVID-19), the COVID-19 pandemic period and locality.

RESULTS

Areas with better housing and income, but higher health and disability deprivation, showed increased levels of free school meal eligibility following the pandemic. Mental health was insensitive to the first 14 months of pandemic yet is worsened by unemployment deprivation and cardiovascular and respiratory comorbidities, with a greater predisposition to poor mental health in adolescents and young adults. After accounting for the effect of COVID-19, hospital mortality risk increased with demographic influences in fitting with the typology of coastal communities having an older population, struggling healthcare and a greater prevalence of comorbidities.

CONCLUSIONS

Public health managers and policy makers seeking to prevent worsening health and well-being within coastal communities following the pandemic should focus on broader-scale patterns reflecting entrenched poor health typical of coastal communities, and emerging food insecurity within specific demographic and deprivation groups at finer scales.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

Financial strain and depression in the U.S.: a scoping review

While the association between assets and depression has been established, less is known about the link between financial strain and depression. Given rising financial strain and economic inequity due to the COVID-19 pandemic, understanding the role that financial strain plays in shaping population depression in the United States is particularly salient. We conducted a scoping review of the peer-reviewed literature on financial strain and depression published from inception through January 19, 2023, in Embase, Medline via PubMed, and PsycINFO, PsycArticles, SocINDEX, and EconLit via Ebsco. We searched, reviewed, and synthesized the literature on longitudinal studies on financial strain and depression conducted in the United States. Four thousand and four unique citations were screened for eligibility. Fifty-eight longitudinal, quantitative articles on adults in the United States were included in the review. Eighty-three percent of articles (n = 48) reported a significant, positive association between financial strain and depression. Eight articles reported mixed results, featuring non-significant associations for some sub-groups and significant associations for others, one article was unclear, and one article reported no significant association between financial strain and depression. Five articles featured interventions to reduce depressive symptoms. Effective interventions included coping mechanisms to improve one's financial situation (e.g., mechanisms to assist in finding employment), to modify cognitive behavior (e.g., reframing mindset), and to engage support (e.g., engaging social and community support). Successful interventions were tailored to participants, were group-based (e.g., they included family members or other job seekers), and occurred over multiple sessions. While depression was defined consistently, financial strain was defined variably. Gaps in the literature included studies featuring Asian populations in the United States and interventions to reduce financial strain. There is a consistent, positive association between financial strain and depression in the United States. More research is needed to identify and test interventions that mitigate the ill effects of financial strain on population's mental health.

Cumulative effects of pre-pandemic vulnerabilities and pandemic-related hardship on psychological distress among pregnant individuals

OBJECTIVE

Our primary objective was to determine whether pre-existing vulnerabilities and resilience factors combined with objective hardship resulted in cumulative (i.e., additive) effects on psychological distress in pregnant individuals during the COVID-19 pandemic. A secondary objective was to determine whether any of the effects of pandemic-related hardship were compounded (i.e., multiplicative) by pre-existing vulnerabilities.

METHOD

Data are from a prospective pregnancy cohort study, the Pregnancy During the COVID-19 Pandemic study (PdP). This cross-sectional report is based upon the initial survey collected at recruitment between April 5, 2020 and April 30, 2021. Logistic regressions were used to evaluate our objectives.

RESULTS

Pandemic-related hardship substantially increased the odds of scoring above the clinical cut-off on measures of anxiety and depression symptoms. Pre-existing vulnerabilities had cumulative (i.e., additive) effects on the odds of scoring above the clinical cut-off on measures of anxiety and depression symptoms. There was no evidence of compounding (i.e., multiplicative) effects. Social support had a protective effect on anxiety and depression symptoms, but government financial aid did not.

CONCLUSION

Pre-pandemic vulnerability and pandemic-related hardship had cumulative effects on psychological distress during the COVID-19 pandemic. Adequate and equitable responses to pandemics and disasters may require more intensive supports for those with multiple vulnerabilities.

Area disadvantage and mental health over the life course: a 69-year prospective birth cohort study

PURPOSE

Existing evidence on the mental health consequences of disadvantaged areas uses cross-sectional or longitudinal studies with short observation periods. The objective of this research was to investigate this association over a 69-year period.

METHODS

Data were obtained from the MRC National Survey of Health and Development (NSHD; the British 1946 birth cohort), which consisted of 2125 participants at 69 years. We assessed longitudinal associations between area disadvantage and mental health symptoms at adolescence and adulthood with use of multilevel modelling framework.

RESULTS

After adjustment for father's social class, for each one percentage increase in area disadvantage at age 4, there was a 0.02 (95% CI 0.001, 0.04) mean increase in the total score of the neuroticism scale at age 13-15. After adjustment for father's social class, adult socio-economic position, cognitive ability and educational attainment, a one percentage increase in change score of area disadvantage between age 4 and 26 was associated with a mean increase in the total Psychiatric Symptom Frequency score (MD 0.06; 95% CI 0.007, 0.11). Similar associations were observed with change scores between ages 4, 53, 60 and total General Health Questionnaire-28 score at age 53 (MD 0.05; 95% CI 0.01, 0.11) and 60-64 (MD 0.06; 95% CI 0.009, 0.11).

CONCLUSIONS

Cohort members who experienced increasing area disadvantage from childhood were at increased risk of poor mental health over the life course. Population-wide interventions aiming at improving social and physical aspects of the early neighbourhood environment could reduce the socio-economic burden of poor mental health.

Understanding the psychological therapy treatment outcomes for young adults who are not in education, employment, or training (NEET), moderators of outcomes, and what might be done to improve them

BACKGROUND

To determine: whether young adults (aged 18-24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET.

METHODS

A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment.

RESULTS

Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63-0.74), for deterioration = 1.41 (1.25-1.60), and for attrition = 1.31 (1.19-1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08-1.12), deterioration = 0.94 (0.91-0.98), and attrition = 0.68 (0.66-0.71).

CONCLUSIONS

Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.

Mental Health, Material Possessions, and Social Capital During COVID-19: A Study of the United States Urban Working-Age Population

This study evaluates the associations between the urban working-age population's mental health, material possession, and social capital during the COVID-19 pandemic. The specific stressors examined in this empirical analysis are income level, food insecurity, and virtual psychological support. This paper further examines the differences across the employed and unemployed population groups. We obtained data from the COVID-19 Household Impact Survey and constructed four measures of mental health conditions: Nervous, Depressed, Lonely, and Hopeless. Our empirical analyses use an ordinal regression model that takes both time and regional factors into consideration to control for potential time effects and time-invariant confounders that only vary between regions. For the employed group, the main results suggest that lower income and food insecurity is correlated with a higher frequency of mental health symptoms, while virtual psychological support predicts a better mental health status. For the unemployed group, food insecurity is negatively associated with mental health, and virtual psychological might help alleviate nervousness and depression.

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.

Mental health promotion and protection relating to key life events and transitions in adulthood: a rapid systematic review of systematic reviews

BACKGROUND

During the decades representing working-age adulthood, most people will experience one or several significant life events or transitions. These may present a challenge to mental health.

AIM

The primary aim of this rapid systematic review of systematic reviews was to summarise available evidence on the effectiveness of interventions to promote and protect mental health relating to four key life events and transitions: pregnancy and early parenthood, bereavement, unemployment, and housing problems. This review was conducted to inform UK national policy on mental health support.

METHODS

We searched key databases for systematic reviews of interventions for working-age adults (19 to 64 years old) who had experienced or were at risk of experiencing one of four key life events. Titles and abstracts were screened by two reviewers in duplicate, as were full-text manuscripts of relevant records. We assessed the quality of included reviews and extracted data on the characteristics of each literature review. We prioritised high quality, recent systematic reviews for more detailed data extraction and synthesis.

RESULTS

The search and screening of 3997 titles/abstracts and 239 full-text papers resulted in 134 relevant studies, 68 of which were included in a narrative synthesis. Evidence was strongest and of the highest quality for interventions to support women during pregnancy and after childbirth. For example, we found benefits of physical activity and psychological therapy for outcomes relating to mental health after birth. There was high quality evidence of positive effects of online bereavement interventions and psychological interventions on symptoms of grief, post-traumatic stress, and depression. Evidence was inconclusive and of lower quality for a range of other bereavement interventions, unemployment support interventions, and housing interventions.

CONCLUSIONS

Whilst evidence based mental health prevention and promotion is available during pregnancy and early parenthood and for bereavement, it is unclear how best to support adults experiencing job loss, unemployment, and housing problems.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

COVID-19 and Mental Health Concerns Among Business Owners: a Cross-Sectional Study from India

The study examines the relationship between pandemic-induced financial distress and mental health of entrepreneurs in India. A cross-sectional research design was used, and a survey was conducted among 816 small-scale entrepreneurs of diverse business entities. Structural equation modeling was performed to analyze the data. Both economic hardship and financial threat reported significant positive relationships with depression, anxiety, and stress. Financial wellbeing was found to be negatively related with depression, anxiety, and stress. The study stands among pioneers who have investigated the mental health issues among entrepreneurs during the COVID-19 pandemic. The study provides holistic implications by recommending a collective mechanism that involves individuals, governments, and institutions, for helping small business entrepreneurs cope with the situation, avoid trauma, and have a positive mental health. Future studies can focus on longitudinal data collection to provide better accuracy and consistency.

The Acceptability and Initial Effectiveness of “Space From Money Worries”: An Online Cognitive Behavioral Therapy Intervention to Tackle the Link Between Financial Difficulties and Poor Mental Health

Background

Previous research has shown a strong relationship between financial difficulties and mental health problems. Psychological factors such as hope and worry about finances appear to be an important factor in this relationship.

Objective

To develop an online based psychological intervention (Space from Money Worries) to tackle the psychological mechanisms underlying the relationship between poor mental health and financial difficulties, and to conduct an initial evaluation of the acceptability and preliminary efficacy of the intervention.

Materials and Methods

30 participants accessing Increasing Access to Psychological Therapies (IAPT) services completed GAD-7 to measure anxiety and PHQ-9 to measure depression upon signing up to the online intervention and again 4 to 8 weeks after this. Participants also completed a measure of perceived financial distress/wellbeing and a “Money and Mental Health Scale” constructed for the evaluation.

Results

Overall, 77% (n = 23) completed the intervention and follow-up assessments. Intent to Treat Analysis showed that there were statistically significant improvements in symptoms of depression, anxiety, improved perceived financial wellbeing and reduced scores on the money and mental health scale. The vast majority of participants rated each module positively.

Conclusions

Space from Money Worries appears to be acceptable and may lead to improvements in mental health, perceived financial wellbeing and a reduced relationship between financial difficulties and poor mental health. However, future research with a larger sample and a control group are needed to confirm that these changes are due to the intervention.

Transition to Labor Market among Young Adults with Serious Mental Illness

Background: The research on job attainment and retention among young adults with serious mental illness (SMI) is limited. The objective of this study was to investigate the contributions of emotional, cognitive, motor, demographic, and work-related factors to the transition into supported employment (SE) and retention. Methods: This cross-sectional study included young adults with SMI involved in prevocational (N = 21) services or those who have transferred to SE (N = 21) following prevocational services. Work-related self-efficacy, executive functions, and motor skills were approached with standard and well-established tools. Results: There was a significant difference between groups in most dimensions of work-related self-efficacy, job history and experience, cognitive strategies, and general independence in daily life. The multivariate analysis demonstrates that holding a profession, experiencing self-efficacy in general work skills, cognitive strategies, and independence in living situations explained the between-group differences (χ2(4) = 34.62, p < 0.001; correct classification−90.2%). Conclusions: The study identifies the factors contributing to a sustainable transition to employment among young adults with SMI, suggesting the importance of a comprehensive approach to address a range of personal factors in an integrative way. The augmentation of prevocational training with continued employment support may be beneficial to meet the unique needs of young adults with SMI.

Projected all-cause deaths attributable to COVID-19-related unemployment in Croatia in 2020

Objectives

In 2020, Croatia reported the first increase in the unemployment rate after six consecutive years of reduction in the number of unemployed persons. Unemployment is associated with an increase in morbidity and mortality among unemployed persons. We estimated the number of potential excess deaths that could be associated with an increase in unemployment seen after the beginning of the COVID-19 pandemic in 2020.

Study design

This was a cross-sectional analytic study.

Methods

We used previously published meta-analyzed hazard ratios for the unemployment–mortality association and unemployment and mortality data from the Croatian Bureau of Statistics to estimate 1-year age-standardized deaths potentially attributable to COVID-19–related unemployment for persons aged 20–64 in Croatia.

Results

In January 2021, we observed a 19% increase in unemployment among persons aged 20–64 years compared with February 2020 (prepandemic). This increase in unemployment could lead to 23 excess deaths among newly unemployed persons. This would constitute a 42% increase in the number of deaths and 29% of all deaths among this group. Deaths were disproportionately higher among men and those aged >40 years.

Conclusions

To mitigate the negative impact of COVID-19–related unemployment on population health, interventions that will reduce the further spread of SARS-CoV-2 and policies that will ensure economic recovery and reduction of unemployment are needed. Job skills training and provision of legal and welfare advice programs for unemployed persons should be integrated with health interventions.

Unemployment as a Medical and Social Problem and Incidence among Unemployed Young People

BACKGROUND: The problem of unemployment among young people worries the world for many generations, since young people are the stratum of the population on which the future in each country depends (Brydsten et al. 2016). The socioeconomic situation of young people, especially the unemployed, is alarming, which is not always emphasized in the priorities of social policy. The study of incidence among unemployed youth is carried out in many countries, where it is noted that the unemployed people have worse mental and physical health compared to employed one (Grzegorczyk and Wolff, 2020). AIM: Our study aims to assess the difference between the incidence of working and unemployed youth. METHODS: The study involved 536 people, from 18 to 29-years-old, among whom women - 69.2%, men - 30.8%, from all regions of Kazakhstan. RESULTS: The results of the work showed that the level of youth unemployment increased during the pandemic by an average of 1% in the world and in Kazakhstan, young people had limitations in receiving medical and social assistance due to financial constraints, deficiency of health insurance and personal reluctance. It was also found that social status is a significant predictor of vaccination (beta = −0.225, R2 = 0.0507, p < 0.001) and a predictor of alcohol consumption (beta = −0.0908, R2 = 0.00824, p = 0.037). More often unemployed youth noted health problems over the past year (42.3%) than in other social groups (35.6–37.8%), a similar situation was observed when assessing the frequency of chronic diseases (p = 0.365). CONCLUSION: In our study, we show that the decline in health by virtue of unemployment is likely to be significant, since our estimated effect implies that the health of young people is almost 10% worse (in absolute terms) due to unemployment compared to the employed population. This further underscores that unemployment is a public health problem that needs more attention. Furthermore, the results obtained show that unemployment has the most negative consequences for vulnerable people, including young people.

Effectiveness of a return to work intervention after occupational disability retirement due to depression and anxiety

Depression and anxiety disorders are the most common cause for disability retirement among people of middle age. The following social disintegration can have an additional detrimental effect on subjects' psychological well-being, which further reduces their chances for recovery. Long-term disability could be avoidable in many cases as depression and anxiety disorders don't have an etiology that makes permanent loss of function inevitable. This prospective cohort study tests the long-term effects of an intervention addressed at these young disablement retirees. Forty-one subjects each in the experimental and control group were followed-up on over a period of 24 months. The intervention had positive effects on psychological well-being. More subjects returned to work than controls. The effects were still present at one year follow-up. These findings show that an individually tailored return-to-work intervention is a useful, sustainable and economically advantageous therapeutic tool to get out of disability retirement due to mental illness even after all other therapeutic tools have failed.

MS JobSeek: A pilot randomized controlled trial of an online peer discussion forum for job-seekers with multiple sclerosis

BACKGROUND: Peer-facilitated interventions have been successfully used in chronic disease management. Less is known about their application in vocational rehabilitation. OBJECTIVE: To pilot-test an online peer discussion forum to improve exploration of employment options in job-seekers with long-term multiple sclerosis (MS). METHODS: Twenty-nine persons with relapsing/progressive MS (4–27 years since diagnosis) were recruited online and randomly assigned to an 8-week discussion forum led by peers and a moderator, MS JobSeek (n = 14), or an active control group (n = 15). Forum engagement and user satisfaction were examined, as were pre-post self-evaluations of job search behaviour, efficacy, and quality of life. RESULTS: A high (43%) attrition rate was noted, although intervention completers acknowledged and valued online mentors’ guidance and expertise. Group and time effects were not significant (p < 0.05), with both MS JobSeek and control participants reporting positive (e.g., increase in job search activities) and negative (e.g., lowered self-efficacy) change. CONCLUSIONS: The pilot findings suggest that online peer support is feasible, however more can be done to promote peer-to-peer communication. Recommendations for improving forum engagement and satisfaction in a future controlled trial, including strategies to better support mentees’ individualised needs, are offered.

Economic Recession and the Long Term Risk of Psychiatric Disorders and Alcohol Related Diseases-A Cohort Study From Eastern Finland

BACKGROUND

Long-term development of psychiatric disorders and alcohol-related diseases after economic recessions is insufficiently studied. We investigated the overall impact of the economic recession between 1991 and 1994 in Finland on the long-term incidence of psychiatric and alcohol-related diseases.

METHODS

A population-based sample of 1,774 women and men aged 53-73 years were examined between 1998 and 2001 from the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD). Participants completed comprehensive questionnaires on the possible impact of the 1990s recession in Finland on their lives. They were followed-up until 2018. Cox proportional hazards regression was used to estimate hazard ratios (HR) of new incident psychiatric and alcohol-related disorders during the 20-years follow-up after linkage to the National Hospital Registry. Logistic regression was used to estimate odds ratios (OR) of psychiatric disorders at baseline.

RESULTS

At baseline, 93 participants had psychiatric disorders. During 20-years follow-up, 138 new psychiatric disorders and 45 alcohol-related diseases were developed. The covariate-adjusted risk of psychiatric disorders was over twice higher among men who experienced recession-induced hardships compared to those who did not (HR = 2.20, 95%CI = 1.04-4.70, p = 0.04). The risk of alcohol-related diseases was more than four times higher among men with hardships (HR = 4.44, 95%CI = 1.04-18.90, p = 0.04). No such associations were observed among women. No association was observed between recession-induced hardships and having psychiatric disorders at baseline in both genders (multivariate-adjusted p = 0.63 for women, multivariate-adjusted p = 0.36 for men).

CONCLUSION

Long-term risk of psychiatric disorders and alcohol-related diseases was increased after the 1990s economic recession in Finland, but only among middle-age and older men.

Sex Differences in Heart Failure

Heart failure (HF) continues to be a major contributor of morbidity and mortality for men and women alike, yet how the predisposition for, course and management of HF differ between men and women remains underexplored. Sex differences in traditional risk factors as well as sex-specific risk factors influence the prevalence and manifestation of HF in unique ways. The pathophysiology of HF differs between men and women and may explain sex-specific differences in clinical presentation and diagnosis. This in turn contributes to variation in response to both pharmacologic and device/surgical therapy. This review examines sex-specific differences in HF spanning prevalence, risk factors, pathophysiology, presentation, and therapies with a specific focus on highlighting gaps in knowledge with calls to action for future research efforts.

Trends in young adults' mental distress and its association with employment: Evidence from the Behavioral Risk Factor Surveillance System, 1993-2019

Few have examined how employment is linked to trends in mental health among young adults across economic contexts in more recent years. To better understand the burden of non-employment and mental distress in this age group, this study examines the association of short-term (<1 year) and long-term (1+ year) out-of-work status with mental health across three recessions among young men and women ages 18-34. We report sex-stratified estimates of frequent mental distress (FMD), out-of-work status, and their association through adjusted prevalence ratios across 27 cycles of the U.S. Behavioral Risk Factor Surveillance System (1993-2019). We found that FMD increased by 112% in men and 120% in women between 1993 and 2019, with 55% (men) and 44% (women) of this increase occurring between 2016 and 2019. Short-term (PR men = 1.53, 95%CI 1.46-1.61; PR women = 1.34, 95%CI 1.29-1.40) and long-term (PR men = 1.61, 95%CI 1.51-1.71; PR women = 1.28, 95%CI 1.22-1.34) out-of-work status were each associated with a higher risk of FMD during this period. The magnitude of associations between long-term out-of-work status and FMD significantly varied across cycles, and was strongest after the 1991 recession in men and the 2008 recession in women. Whereas employment represents an important determinant of mental health among young adults, particularly during economic downturns, it did not suffice to explain the rise in mental distress in this age group in more recent years.

Effectiveness of community interventions for protecting and promoting the mental health of working-age adults experiencing financial uncertainty: a systematic review

BACKGROUND

The COVID-19 pandemic has created a period of global economic uncertainty. Financial strain, personal debt, recent job loss and housing insecurity are important risk factors for the mental health of working-age adults. Community interventions have the potential to attenuate the mental health impact of these stressors. We examined the effectiveness of community interventions for protecting and promoting the mental health of working-age adults in high-income countries during periods of financial insecurity.

METHODS

Eight electronic databases were systematically screened for experimental and observational studies published since 2000 measuring the effectiveness of community interventions on mental health outcomes. We included any non-clinical intervention that aimed to address the financial, employment, food or housing insecurity of participants. A review protocol was registered on the PROSPERO database (CRD42019156364) and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

From 2326 studies screened, 15 met our inclusion criteria. Five categories of community intervention were identified: advice services colocated in healthcare settings; link worker social prescribing; telephone debt advice; food insecurity interventions; and active labour market programmes. In general, the evidence for effective and cost-effective community interventions delivered to individuals experiencing financial insecurity was lacking. From the small number of studies without a high risk of bias, there was some evidence that financial insecurity and associated mental health problems were amenable to change and differences by subpopulations were observed.

CONCLUSION

There is a need for well-controlled studies and trials to better understand effective ingredients and to identify those interventions warranting wider implementation.

Moving clients forward: a grounded theory of disability employment specialists' views and practices

PURPOSE

This study sought to better understand the views and practices of disability employment specialists working with clients with mental illness. Specifically, it explored what helps and hinders employment specialists in their work.

MATERIALS AND METHODS

A constructivist grounded theory methodology was used. Semi-structured interviews with 16 disability employment specialists from four employment service providers in Victoria, Australia, were transcribed and analysed through initial coding, focused coding, and constant comparative methods.

RESULTS

Analysis led to the substantive grounded theory of "moving clients forward." The key themes included "taking a firm but fair approach," "meeting clients where they are at," "getting clients ready for work," "managing the interface between clients and employers," and as a consequence, "working under pressure."

CONCLUSIONS

These findings contribute the first grounded theory of how Australian disability employment specialists work with clients with mental illness and enhance understanding of employment specialists' notions of job readiness and their use of discretion in implementing seemingly contradictory employment-related policies. Practice tensions for these employment specialists could be reduced by modifying disability employment policies, and through training to deliver evidence-based practices that offer varied vocational services, pathways, and adjunct interventions tailored to clients' interests, needs and readiness for change.IMPLICATIONS FOR REHABILITATIONAustralian disability employment specialists experience tensions between meeting the needs of clients with mental illness and feeling pressured to adhere to performance-based funding and disability employment policies.Greater emphasis on evidence-based, individualised vocational interventions would better align with a recovery orientation and offer vocational options tailored to the needs and goals of job seekers with mental illnessFurther training and systemic support is needed for disability employment specialists to adopt evidence-based practices in their work with jobseekers with mental illness.Since Australian disability employment specialists describe considering the "job readiness" of clients in practice, the usefulness of this concept merits further investigation.

The impact of Active Labour Market Policies on health outcomes: a Scoping review

BACKGROUND

Since the last Western great recession of 2008, an increasing interest on the effects of Active Labour Market Policies (ALMPs) on improving health has emerged. The aim of our review is to synthesize evidence on the effectiveness of ALMPs and whether some types of ALMP are more effective.

METHODS

Using the Scoping review methodology, we conducted a literature review in PubMed/MEDLINE, Scopus and Web of Science and selected articles published between 1990 and 2017 in high income countries. We applied four sequential phases of document screening to the list of retrieved articles.

RESULTS

Of the 416 documents detected in the search, 36 documents were finally selected. Most of them focused on mental health and related components (72.2%) and found positive results at least in one outcome (80.6%). The ALMPs reported mainly attempt to build capacity through job search assistance (31.6%) with a component on mental health, showing positive results on health; some offer job training (16.7%) and few subsidized employment (8.3%), showing more controversial results, although mostly positive. The rest include a combination of different types of ALMPs.

CONCLUSIONS

This review shows that ALMPs have a positive impact on health and quality of life. There are relatively few studies of the impact of ALMPs on general health, and most of the studies found are focused on Anglo-Saxon and Nordic countries. The most significant knowledge gaps are the mechanisms involved in achieving this improvement, and above all the differential health impacts according to axes of inequality and welfare state.

A Return-to-Work Intervention for Prematurely Retired Depression or Anxiety Disorder Patients

Background: Depression and anxiety disorders are the most common cause for premature retirement of people of middle age. These people are expelled from the workforce. The following social disintegration can have an additional detrimental effect on subjects' psychological well-being which further reduces the chance to re-enter the workforce. Depression and anxiety in general need not be regarded as irreversible causes of disability. Therefore, long-term disability should be avoidable in many cases. This two-arm prospective controlled study tests a novel approach for those who have become economically inactive due to their illness with the goal to improve psychological well-being and return to work. Forty-one subjects were followed-up on over a period of 12 months and compared to 41 control cases. ANOVA for repeated measures showed that experimental subjects' psychological well-being and work ability was much better after the intervention than in the control group. These findings show that an individually tailored return-to-work intervention can be a useful therapeutic tool even after retirement.

Mental Health and Wealth: Depression, Gender, Poverty, and Parenting

Depression is a common and debilitating condition that adversely affects functioning and the capacity to work and establish economic stability. Women are disproportionately burdened by depression, and low-income pregnant and parenting women have particularly high rates of depression and often lack access to treatment. As depression can be treated, it is a modifiable risk factor for poor economic outcomes for women, and thus for children and families. Recent national and state health care policy changes offer the opportunity for community-based psychological and economic interventions that can reduce the number of pregnant and parenting women with clinically significant depressive symptoms. Moreover, there is strong evidence that in addition to benefiting women's well-being, such reforms bolster children's emotional and social development and learning and help families rise out of poverty. This review summarizes the mental health and economic literature regarding how maternal depression perpetuates intergenerational poverty and discusses recommendations regarding policies to treat maternal depression in large-scale social services systems.

Evaluating potential mediators for the impact of a family-based economic intervention (Suubi+Adherence) on the mental health of adolescents living with HIV in Uganda

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi + Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.

METHOD

We utilized data from Suubi + Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N = 702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi + Adherence intervention on adolescents' mental health.

RESULTS

Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.

CONCLUSIONS

Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.

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.

Trends in generalised anxiety disorders and symptoms in primary care: UK population-based cohort study

BACKGROUND

Generalised anxiety disorder and symptoms are associated with poor physical, emotional and social functioning and frequent primary and acute care visits. We investigated recent temporal trends in anxiety and related mental illness in UK general practice.

AIMS

The aims of this analysis are to examine temporal changes in recording of generalised anxiety in primary care and initial pharmacologic treatments.

METHOD

Annual incidence rates of generalised anxiety diagnoses and symptoms were calculated from 795 UK general practices contributing to The Health Improvement Network (THIN) database between 1998 and 2018. Poisson mixed regression was used to account for age, gender and general practitioner practice. Subsequent pharmacologic treatment was examined.

RESULTS

Generalised anxiety recording rates increased in both genders aged 18-24 between 2014 and 2018. For women, the increase was from 17.06 to 23.33/1000 person years at risk (PYAR); for men, 8.59 to 11.65/1000 PYAR. Increases persisted for a composite of anxiety and depression (49.74 to 57.81/1000 PYAR for women; 25.41 to 31.45/1000 PYAR for men). Smaller increases in anxiety were seen in both genders age 25-34 and 35-44. Anxiety rates among older patients remained stable, although a composite of anxiety and depression decreased for older women. About half of drug-naïve patients were prescribed anxiety drugs within 1 year following diagnosis. The most common choice was a selective serotonin reuptake inhibitor. Benzodiazepine prescription rate has fallen steadily.

CONCLUSIONS

We observed a substantial increase in general practitioner consulting for generalised anxiety and depression recently, concentrated within younger people and in particular women.

Vocational Service Models and Approaches to Improve Job Tenure of People With Severe and Enduring Mental Illness: A Narrative Review

Employment is a valued occupation that offers a sense of meaning, identity, and belonging. For people with severe and enduring mental illness, employment has also been associated with personal recovery and decreased use of mental health services. However, this population continues to be underrepresented in the labor market. Sustainable employment is often challenging for people with severe and enduring mental illness, due to a combination of personal, organizational and systemic issues. While Individual Placement and Support is an evidence-based model of employment support known to improve job attainment for people with mental illness, job retention and sustained workforce participation continue to be challenges. This narrative literature review was undertaken to address the question: "What vocational service models and approaches improve job tenure for this population?" CinAHL, Medline, Embase, PsycINFO, and Cochrane Library were searched for the period 2005-2020, using key terms and subject headings, including "severe mental illness," "psychiatric disabilit^*," "job tenure," and "job retention." Several adjunct interventions may enhance job retention, including skills training, cognitive interventions, psychological interventions, and supported education, while social firms offer a different approach focused on creating new, sustainable job opportunities. Peer support and support from family and friends also appear to be important, and emerging evidence suggests that employment specialist practices, technology, self-management, and workplace accommodations may each also influence job tenure. Service providers could make more use of these non-clinical vocational approaches to improve employment retention for people with severe and enduring mental illness.

Invited Commentary: Reckoning With the Relationship Between Stressors and Suicide Attempts in a Time of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic presents a unique set of risk exposures for populations, which might lead to an increase in suicide. While large-scale traumatic events are known to increase psychological disorders, thus far the science has not shown a clear link between these events and suicide. In this issue of the Journal, Elbogen et al. (Am J Epidemiol. 2020;189(11):1266-1274) used representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to show that 4 dimensions of financial strain-financial debt/crisis, unemployment, past homelessness, and lower income-are associated with subsequent suicide attempts. There are 3 main lessons we can take from Elbogen et al.: First, with populations facing record-breaking unemployment, economic recession, and reduced wages, we can anticipate an increase in suicide in the wake of the COVID-19 pandemic. Second, these data show the centrality of financial stressors, marking the current moment as distinct from other disasters or large-scale trauma. Third, the data teach us that financial stressors are linked and cumulative. In this way, Elbogen et al. provide a sobering harbinger of the potential effects on suicide of the collective stressors borne by the COVID-19 pandemic and other mass traumatic events that are accompanied by substantial financial stressors.

Social Causation, Social Selection, or Common Determinants? Examining Competing Explanations for the Link Between Young Adult Unemployment and Nicotine Dependence

INTRODUCTION

Unemployment has been related to smoking, yet the causal nature of the association is subject to continued debate. Social causation argues that unemployment triggers changes in smoking, whereas the social selection hypothesis proposes that pre-existing smoking behavior lowers the probability of maintaining employment. The present study tested these competing explanations while accounting for another alternative explanation-common liability.

METHODS

Data were from the Christchurch Health and Development Study, a longitudinal cohort followed from birth to age 35. Odds were generated for having nicotine dependence in models for social causation and being unemployed in models for social selection. These models were extended to include possible common liability factors during childhood (eg, novelty seeking) and young adulthood (eg, major depression).

RESULTS

In the model testing social causation, coefficients representing the impacts of unemployment on nicotine dependence remained statistically significant and robust (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 1.20, 2.00), even after accounting for common determinant measures. In contrast, a reverse social selection model revealed that coefficients representing the impacts of nicotine dependence on unemployment substantially attenuated and became statistically nonsignificant as childhood factors were added (OR = 1.14; 95% CI = 0.90, 1.45).

CONCLUSIONS

Unemployment may serve as inroads to nicotine addiction among young adults, not the other way, even in the context of nicotine dependence, a more impaired form of smoking that may arguably hold higher potential to generate social selection processes. This social causation process cannot be completely attributable to common determinant factors.

IMPLICATIONS

It is critical to clarify whether unemployment triggers changes in smoking behaviors (ie, social causation) or vice versa (ie, social selection)-the answers to the question will lead to public health strategies with very different intervention targets to break the linkage. The current study findings favor social causation over social selection, regardless of gender, and support a needed shift in service profiles for unemployed young adults-from a narrow focus on job skills training to a more holistic approach that incorporates knowledge from addiction science in which unemployed young adults can find needed services to cope with job loss.

The effect of gender on mental health service use: an examination of mediation through material, social and health-related pathways

PURPOSE

We aimed to understand how much of the gender difference in mental health service use could be due to the joint mediation of employment, behavioural and material factors, social support and mental health need.

METHODS

We used data from employed individuals aged 18-65 years who participated in the 2015-2017 waves of the Household, Income and Labour Dynamics in Australia survey. The exposure (male, female) and confounders were measured in 2015, mediators in 2016 and the outcome-whether a person had seen a mental health professional in the previous year-was measured in 2017. We estimated natural mediation effects using weighted counterfactual predictions from a logistic regression model.

RESULTS

Men were less likely to see a mental health care provider than women. The total causal effect on the risk difference scale was  - 0.045 (95% CI  - 0.056,  - 0,034). The counterfactual of men taking the mediator values of women explained 28% (95% CI 1.7%, 54%) of the total effect, with the natural direct effect estimated to represent an absolute risk difference of  - 0.033 (95% CI  - 0.048,  - 0.018) and the natural indirect effect  - 0.012 (95% CI  - 0.022,  - 0.0027).

CONCLUSION

Gendered differences in the use of mental health services could be reduced by addressing inequalities in health, employment, material and behavioural factors, and social support.

Impacts of Layoffs and Government Assistance on Mental Health during COVID-19: An Evidence-Based Study of the United States

This study evaluates the impact of unemployment and government financial assistance during the COVID-19 pandemic on the working-age population’s mental health and further examines the differential impacts between urban and non-urban groups, as well as African American (AA) and non-African American groups. Based on the COVID-19 Household Impact Survey, four measures of mental health conditions (nervous, depressed, lonely, and hopeless) are constructed. Our empirical analysis applies the ordinal regression model (ordered logit model) that takes both the week and regional factors into consideration to control for potential time effects and time-invariant confounders varying across regions. The results show that government aid only mitigates the psychological symptoms for the group in non-urban areas, with no significant impacts on the urban group. On the other hand, the AA working-age group experiences similar or more favorable mental health than other ethnic groups, while government aid does not alleviate the mental pressure for the AA group. Therefore, government interventions should recognize the heterogeneity of impacts on socioeconomic groups within the target population.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Should GPs ask patients about their financial concerns? Exploration through collaborative research

Objective: Health services should arguably be concerned about the financial situation of patients since health problems can cause financial concerns, which in turn can cause health problems. In this study, we explored the role of the general practitioner (GP) as a potential early discoverer of financial problems who can refer at-risk patients to financial counselling services.Design: A collaborative health service research experiment. For four weeks, GPs asked their patients predefined questions about financial concerns and health, by anonymous data mapping. GPs shared their experiences with the researchers after the experiment.Setting: One GP office in Norway.Subjects: A total of 565 patients were included in data mapping by 8 GPs.Main outcome measures: Patient prevalence data and GPs experimental data of patients' health problems that caused financial concerns and financial concerns that affected patients' health.Results: Of 565 GP patients, 11% (n = 63) indicated that they had health problems causing them financial concerns, or vice versa; 9% of patients reported health problems causing financial concerns and 8% of patients reported financial concerns that affected their health. Through the data mapping experiment GPs became aware of financial concerns of their patients and by this expanded and improved their therapeutic toolbox. Several months after the experiment the GPs reported that more patients received financial counselling since the GPs asked their patients about financial problems more often than before and because the patients had heard that GPs cared about such problems.Conclusion: Our results suggest that GPs can be early discoverers of financial problems interacting with their patients' health. When there are no clear medical explanations for the health problems that prompted the consultation, the best therapy may thus be financial counselling.Key pointsMany people live on the edge of financial ruin and struggle to keep track of their finances, but limited research exists that investigates associations between finance and health.In a collaborative health services research experiment 11% of the patients at a Norwegian GP office had health problems that caused them financial concerns, or vice versa.GPs found it helpful to ask patients about their financial concerns when no clear medical explanations for their health problems was found. Then free financial counselling services could be offered.

Health promotion and prevention among the unemployed: a systematic review

The interactions between unemployment and health create a need for specific interventions for health promotion and prevention. This overview provides information on how health promotion for the unemployed has been approached with an analysis of controlled intervention studies between 1996 and 2016. The literature search consulted 11 international databases in medicine, social sciences and psychology. A total of 30 health interventions for the unemployed were identified, with 43 articles that included the effects of intervention. A controlled-study design was used in 14 studies. The health promotion measures were generally based on individual counselling, case management, training or group services. The overview demonstrates the breadth of variation in target groups and types of measures. Their result indicators for health and integration into the labor market vary substantially, as do the employment promotion effects. There is evidence of improved health and labor market integration for established approaches like the JOBS Program and JobFit. Effects are rather moderate or low in magnitude and the effect mechanisms often remain unclear. Effects weaken over time. While success is more common in the areas of health, physical activity, nutrition and stress relief, there was no impact on smoking behavior. A significant evolution can be observed in the quality and quantity of health promotion for the unemployed over time. There is a need for further research on the effectiveness and sustainability of interventions. Intervention strategies should be developed that take account of the diversity of the unemployed and their different needs.

The role of social integration in the adverse effect of unemployment on mental health - Testing the causal pathway and buffering hypotheses using panel data

Social integration is considered crucially important for understanding the adverse effect of unemployment on mental health. Social integration is assumed to either bring about the health effects of unemployment (causal pathway hypothesis) or shield the unemployed from such effects (buffering hypothesis). However, there is scarce empirical evidence, especially based on panel data, regarding these two hypotheses. In our analysis, we use up to ten waves of the "Labour Market and Social Security" (PASS) German panel study and apply fixed effects panel regressions to account for unobserved confounders. We test several indicators that cover different aspects of social integration (numbers of strong and weak ties, conflict in the household, employed friends, general and job search-specific social support). We find no empirical support for the causal pathway hypothesis and only very limited support for the buffering hypothesis.

Health-improving interventions for obtaining employment in unemployed job seekers

BACKGROUND

Unemployment is associated with decreased health which may be a reason or a consequence of becoming unemployed. Decreased health can inhibit re-employment.

OBJECTIVES

To assess the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers.

SEARCH METHODS

We searched (3 May 2018, updated 13 August 2019) the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, PsycINFO, CINAHL, SocINDEX, OSH Update, ClinicalTrials.gov, the WHO trials portal, and also reference lists of included studies and selected reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers. The primary outcome was re-employment reported as the number or percentage of participants who obtained employment. Our secondary outcomes were health and work ability.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted outcome data, and assessed risk of bias. We pooled study results with random-effect models and reported risk ratios (RRs) with 95% confidence intervals (CIs) and assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 15 randomised controlled trials (16 interventions) with a total of 6397 unemployed participants. Eight studies evaluated therapeutic interventions such as cognitive behavioural therapy, physical exercise, and health-related advice and counselling and, in seven studies, interventions were combined using therapeutic methods and job-search training. Therapeutic interventions Therapeutic interventions compared to no intervention may increase employment at an average of 11 months follow-up but the evidence is very uncertain (RR = 1.41, 95% CI 1.07 to 1.87, n = 1142, 8 studies with 9 interventions, I² = 52%, very low-quality evidence). There is probably no difference in the effects of therapeutic interventions compared to no intervention on mental health (SMD 0.12, 95% CI -0.06 to 0.29, n = 530, 2 studies, low-quality evidence) and on general health (SMD 0.19, 95% CI -0.04 to 0.41, n = 318, 1 study, moderate-quality evidence). Combined interventions Combined interventions probably increase employment slightly compared to no intervention at an average of 10 months follow-up (RR 1.12, 95% CI 1.06 to 1.20, n = 4101, 6 studies, I² = 7%). There were no studies that measured work-ability, adverse events, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Interventions combining therapeutic methods and job-search training probably have a small beneficial effect in increasing employment. Therapeutic interventions may have an effect on re-employment, but we are very uncertain. Therapeutic interventions may not improve health in unemployed job seekers. Large high-quality RCTs targeting short-term or long-term unemployed people are needed to increase the quality of the evidence. A cost-effectiveness assessment is needed of the small beneficial effects.

Identifying Individuals at High Risk for Permanent Disability From Depression and Anxiety

Mental illnesses, among which depression and anxiety are most common, are the leading cause for permanent disability. It is of interest to know what case characteristics determine if a person returns to the work force in spite of mental illness to tailor specific interventions. So far, there has been little research into this field. In the present study a sample of 202 workers who had permanent disability due to depression/anxiety were followed-up on. 22% started some kind of work during follow-up in a period of 30 to 75 months. Logistic regression analyses showed that quick progression into disability, short period of disability, younger age, adequacy of income replacement through insurance benefits and no previous disability predicted return to work. These findings also allow to identify individuals at high risk for progression into permanent disability that can benefit from supporting interventions.

Psychological distress among the unemployed: Do core self-evaluations and emotional intelligence help to minimize the psychological costs of unemployment?

BACKGROUND

Past research has shown that emotional intelligence (EI) and core self-evaluations (CSE) have a unique and independent role in the prediction of psychological maladjustment in the unemployed population. However, no one to date has examined the joint contribution of EI and CSE in predicting well-being and psychological distress among the unemployed. Our objective was to examine the main and interactive role of EI and CSE in the prediction of indicators for happiness, depression, stress, and anxiety beyond socio-demographics variables.

METHODS

A sample of 1796 unemployed participants completed a battery that included socio-demographic data and questionnaires of EI, CSE, happiness, depression, stress, and anxiety. We processed the data with SPSS and Hayes PROCESS macro.

RESULTS

Pearson correlation analyses showed significant associations between EI and CSE with different mental health outcomes. Moderation analyses revealed that, beyond the main effects, the interactive term EI × CSE increased the explained variance of the prediction of happiness, but not of depression, anxiety, or stress.

LIMITATIONS

The study comprised an incidental non-clinical sample of unemployed adults, so the results might not generalize to a clinical population. Also, the study was cross-sectional, and we relied only on self-report measures, which do not allow for establishing causal links and might include biases, such as social desirability and common method variance.

CONCLUSIONS

These findings highlight the need for developing more comprehensive models including the interaction of EI and dispositional traits as contributing factors in the prediction of positive outcomes among the unemployed. Also, future promotion programs should include dimensions related to EI and CSE for increasing well-being during unemployment.

Recession, recovery and suicide in mental health patients in England: time trend analysis

BACKGROUND

The 2008 economic recession was associated with an increase in suicide internationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.AimsTo investigate suicide trends related to the recession in mental health patients in England.

METHOD

Using regression models, we studied suicide trends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicide and Safety in Mental Health, a national data-set of all suicide deaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death.

RESULTS

Between 2000 and 2016, there were 21 224 suicide deaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000-2009 -0.46%, 95% CI -0.66 to -0.27), suicide rates showed an upward trend during the recession (QPC 2009-2011 2.37%, 95% CI -0.22 to 5.04). Recession-related rises in suicide were found in men aged 45-54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicide in male patients despite an increasing number of patients treated. No significant recession-related trends were found in women.

CONCLUSIONS

Recession-associated increases in suicide were seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicide may be related to an improved economic context or better mental healthcare.Declaration of interestN.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Determinants and Consequences of Financial Hardship Among Adult Survivors of Childhood Cancer: A Report From the St. Jude Lifetime Cohort Study

BACKGROUND

Financial hardship among survivors of pediatric cancer has been understudied. We investigated determinants and consequences of financial hardship among adult survivors of childhood cancer.

METHODS

Financial hardship, determinants, and consequences were examined in 2811 long-term survivors (mean age at evaluation = 31.8 years, years postdiagnosis = 23.6) through the baseline survey and clinical evaluation. Financial hardship was measured by material, psychological, and coping/behavioral domains. Outcomes included health and life insurance affordability, retirement planning, symptoms, and health-related quality of life (HRQOL). Odds ratios (ORs) estimated associations of determinants with financial hardship. Odds ratios and regression coefficients estimated associations of hardship with symptom prevalence and HRQOL, respectively. All statistical tests were two-sided.

RESULTS

Among participants, 22.4% (95% confidence interval [CI] = 20.8% to 24.0%), 51.1% (95% CI = 49.2% to 52.9%), and 33.0% (95% CI = 31.1% to 34.6%) reported material, psychological, and coping/behavioral hardship, respectively. Risk factors across hardship domains included annual household income of $39 999 or less vs $80 000 or more (material OR = 3.04, 95% CI = 2.08 to 4.46, psychological OR = 3.64, 95% CI = 2.76 to 4.80, and coping/behavioral OR = 4.95, 95% CI = 3.57 to 6.86) and below high school attainment vs college graduate or above (material OR = 2.22, 95% CI = 1.45 to 3.42, psychological OR = 1.75, 95% CI = 1.18 to 2.62, and coping/behavioral OR = 2.05, 95% CI = 1.38 to 3.06). Myocardial infarction, peripheral neuropathy, subsequent neoplasm, seizure, stroke, reproductive disorders, amputation, and upper gastrointestinal disease were associated with higher material hardship (all P < .05). Hardship across three domains was associated with somatization, anxiety and depression (all P < .001), suicidal ideation (all P < .05), and difficulty in retirement planning (all P < .001). Survivors with hardship had statistically significantly lower HRQOL (all P < .001), sensation abnormality (all P < .001), and pulmonary (all P < .05) and cardiac (all P < .05) symptoms.

CONCLUSIONS

A substantial proportion of adult survivors of childhood cancer experienced financial hardship. Vulnerable sociodemographic status and late effects were associated with hardship. Survivors with financial hardship had an increased risk of symptom prevalence and impaired HRQOL.

Young Adult Unemployment and Later Depression and Anxiety: Does Childhood Neighborhood Matter?

Young adulthood represents a developmental period with disproportionately heightened risk of losing a job. Young adult unemployment has been linked to increased mental health problems, at least in the short term. However, their possible long-term impacts, often referred as "scarring effects," have been understudied, possibly underestimating the magnitude of mental health burden that young adult unemployment generates. This longitudinal study examined whether duration of unemployment during young adulthood is associated with later mental health disorders, after accounting for mental and behavioral health problems in childhood. Furthermore, the current study investigated whether childhood neighborhood characteristics affect this association and if so, in what specific functional ways. Data were drawn from a longitudinal study of developmental outcomes in a community sample in Seattle. Data collection began in 1985 when study participants were elementary students and involved yearly assessments in childhood and adolescence (ages 10-16) and then biennial or triennial assessments (ages 18-39; N = 677 at age 39; 47% European American, 26% African American, 22% Asian American, and 5% Native American; 49% female). The current study findings suggest that duration of unemployment across young adulthood increased mental health problems at age 39, regardless of gender. Childhood neighborhood characteristics, particularly their positive aspect, exerted independent impacts on adult mental health problems beyond unemployment experiences across young adulthood. The current findings indicate a needed shift in service profiles for unemployed young adults-a comprehensive approach that not only facilitates reemployment but also addresses mental health needs to help them to cope with job loss. Further, the present study findings suggest that childhood neighborhoods, particularly positive features such as positive neighborhood involvement, may represent concrete and malleable prevention targets that can curb mental health problems early in life.