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The prevention of suicidal behaviour is still a land of hopes and promises but not of certainties. In fact, Western countries are facing a general decline in suicide rates that seems unrelated to any national plan aimed at obtaining the desired outcomes in those situations that are known to be associated to suicidal behaviour.1 General improvement in living conditions, better access to care, and more effective treatments of mental disorders are the most probable reasons for the recent decrease in suicide rates in many countries. However, the most recent financial-economic turmoil and the current threatening climate of permanent war will have a foreseeable impact on the standard of living, the consequences of which are still to be evaluated.
Socioeconomic events are known to produce important fluctuations in suicide mortality. Unemployment, in particular, seems related to suicide risk along direct and indirect pathways. Blakely and coworkers’ paper in this issue2 adds to evidence indicating a causal association between unemployment and suicide. Their results indicate that this association is not attributable to confounding factors linked to the socioeconomic status and that it is only partly related to health selection or mental disorders. Statistical analyses permit the authors to calculate that mental illnesses account for about half of the deaths, however the effect of unemployment cannot be discounted solely on this basis. In longitudinal studies unemployment predates symptoms of depression.3 Moreover, the lack of economic independence as a result of unemployment reduces the possibility of using social and health services appropriately: this may prejudice compliance with therapeutically prescribed treatments, contributing to a worsening in the course of a mental disorder.
The most disruptive effect of unemployment, however, acts on social ties at both individual and community level. Measures of social fragmentation, indeed, were found to predict the risk of death by suicide and alcohol related diseases.4
Socioeconomic variables are likely to contribute to the impact of employment status on suicide. In the USA, the lower the socioeconomic status, the higher the suicide risk. However, unemployment adds independently to suicide risk in both men and women.2,5 Other recent studies found that exposure to unemployment is related to suicidal ideation and behaviour, even when taking into account known psychosocial confounding factors and reverse causality.6 Unemployment, therefore, should be considered a true risk factor for suicide.
To exploit this increased awareness of the role of unemployment in the pathways to suicide, however, we need to infuse a creative effort that may take us a little ahead of common sense.
At a first glance, it would seem that the role of clinicians and researchers in fostering public awareness on the role of social factors in negative psychological outcomes would merely end in supporting public welfare programmes. However, suicide rates were found to increase over time in the states that had reduced their per capita expenditure for public welfare; conversely, states that spend more on public welfare also have lower suicide rates.7
This is not, however, the whole story. A closer look at the pathways from unemployment to psychological maladjustment and—hence—to suicide could permit the definition of reasonably practicable strategies aimed at preventing the most negative outcomes.
Job loss usually comprises a whole sequence of stressful events, from anticipation of job loss, to job search, and training for re-employment, when possible. Exclusion from ordinary living patterns, customs, and activities arising from a lack of resources adds independently to the stress caused by job loss, and further increases the risk of depression and subsequent suicide. It is therefore mandatory, whenever a lasting period of unemployment is foreseeable, particularly when middle aged people encounter job loss because of factory closure, to supply a psychological counselling service that may replace the informative, emotional, and material supportive resources diverted by unemployment.
Some pioneering studies found that psychological counselling programmes could prevent the decline in self esteem and mood that generally occurs after being made unemployed.8 Although such a service might be seen by trade unions as an attempt to counteract naturally occurring workers’ rage, and deprive them of the emotional energies useful to carry on conflicts for employment, as perhaps the poorest protocols provide for, a sympathetically lead programme could permit maintaining an adequate psychosocial functioning and the early identification of the most severe disorders, thus preventing their worst outcomes.
Moreover, as it implies a contraction of a person’s social network and a relevant change in the time structure in daily life, job loss may lead to a reduction in surveillance that, together with the availability of lethal means, is another key element in suicide, particularly among mentally troubled people. An effort to provide families with adequate information on this topic could be implemented through first level health resources—that is, the network of general practitioners.
Unemployment is also a considerable source of social stress leading to increased family tensions, increased isolation from others, and the loss of self esteem and confidence. The loss of employment, indeed, implies the loss of social contact and activity, and often leads to the severing of social ties. A well integrated social network plays an important protective part in maintaining mental health, offering support, guidance and assistance, favouring compliance with medical or psychiatric treatment and offering swift aid in the case of a self destructive act. Again, increasing access to health services and resources might reduce the negative impact of job loss. Multiplying the points of entry to the health network, even using the still unexplored potentiality of the internet, ought to favour access to treatment when necessary.
A different set of explanations, grouped under the “health selection” hypothesis, asserts that poorer health by itself, including poorer mental health, increases the risk of unemployment: thus, having a disorder that implies a higher risk of suicide would also lead to unemployment. Even assuming this explanation, which Blakely and coworkers’ paper seems to discount, providing support and working opportunities to mentally suffering patients would protect them from the risk of suicide. In a 20 year prospective study on a large sample of psychiatric outpatients, unemployment was the most evident social factor that had an impact on suicide risk together with clinical ones, such as suicide ideation, and major depressive and bipolar disorders.9 Whenever possible, any effort should be done to keep all the patients with a mental disorder employed.
Paying attention to the immediate health consequences of unemployment also could produce lasting positive effects on public spending. It is interesting to see that growing financial difficulties, which are likely to be linked to rising unemployment rates, are also associated to an increased use of public funded facilities. From 1988 to 1994, for example, the number of patients discharged from US hospitals with a diagnosis of a mental illness increased from 1.4 to 1.9 millions over the whole period.10 In particular, the rate of discharges with a diagnosis of a severe mental illness significantly increased from 196 to 314 per 100 000 of the general population. It seems that the change in mental health care provision that occurred in the USA with the institution of the Medicaid program diverted the most severe patients to the public sector, so that public programmes have increasingly replaced private insurance as the most important source of payment in the USA.
Being creative in counteracting the most negative consequences of unemployment could therefore usefully interlace with current active public health programmes, which emphasise costs containment and saving. Any effort will be in vain, however, if the clinicians fail to use the most sensitive instrument they have: the ability to listen to patients and their families’ complaints. Always ask: how is your work going?
How is your work going?