Over the past 20 years, mortality rates for drug overdose and suicide have increased in USA across all ages, but most dramatically for working-aged adults.^{1 2} Case and Deaton were the first to note rising midlife mortality rates among Caucasian, non-Hispanic Americans aged from 35 to 54 with a high school education or less.³ They identified drug overdose, suicide and alcohol-related liver disease mortality as the causes of the increase and attributed these ‘deaths of despair’ to reduced economic opportunity among less educated adults.⁴

Increases in these ‘deaths of despair’ have since been identified across multiple race and ethnic groups and geographic contexts.^{5 6} Rising mortality rates have been reported for US African Americans, Hispanics, Asians and Pacific Islanders, 25–64 years of age, with drug overdoses the leading cause of the recent increases in all these subpopulations.^{5 6} Reversing decades of steady decline in all-cause mortality for African Americans and Caucasians,³ these disturbing shifts are particularly pronounced for midlife individuals without a bachelor’s degree.⁷ Suicide rates have also increased by 33% since 2000, with the steepest increase for Caucasian men.⁸ Though the rise has been less dramatic for suicide than for overdose, it emerged in 2016 as the fourth leading cause of death among adults, aged 35–54.⁹ Rural counties had consistently higher suicide rates than metropolitan counties.¹⁰

Coincident with the increases in midlife mortality rates, the long-term decline in US manufacturing has limited good employment options for many less educated adults. In the 1970s, 36% of all employed US men worked in manufacturing, and in 2018, only 15% did.¹¹ The most dramatic decreases have occurred since 2000, with a loss of over 5 million jobs.¹² As these well-paying jobs with standard employer–employee relationships and job security have declined, precarious work has been on the rise.¹³ Prior to the Great Recession, China’s entry into the World Trade Organization in 2001 accelerated its export surge in manufacturing and contributed to US contraction.¹⁴ Impacts of the China Shock are most visible in the local labour markets with a concentration of industries exposed to foreign competition where workers who lose jobs may end up out of the job market entirely.¹⁵

The US automobile industry offers a striking case study of an impacted industry in decline. From the 1950s until the China Shock of the early 2000s, the ‘Big Three’ Detroit companies Ford, Chrysler and General Motors (GM) dominated the automobile market. By the late 1960s, foreign automakers began to capture a share of the domestic market. The oil embargo in 1979 further fuelled the rise of imported smaller cars. Detroit automakers responded by shifting to light trucks, minivans, sports utility vehicles and pick-up trucks. Between 1980 and 1996, stronger vehicle safety regulations, increasing oil prices and the emergence of hybridised vehicles further challenged the domestic industry. By 2008, Toyota had become the largest producer worldwide, a title GM had held for 77 years.¹⁶ After the US financial crisis in 2008, the US government bailed out the automobile industry at a cost of $80 billion and restructured GM and Chrysler after they entered bankruptcy in 2009.

This study focuses on the implications of the erosion of the US automobile industry for the mental health and safety of Michigan autoworkers who faced potential job loss. Involuntary worker exit has been found to have substantial effects on depressive symptoms, even after adjusting for baseline health.¹⁷ Taking advantage of individual-level data from an existing study of a United Autoworkers-General Motors (UAW-GM) cohort, we examine associations between worker exit and risk of suicide and fatal overdose. The cohort includes workers at three GM manufacturing facilities in Michigan—one located in an urban centre, one in a more rural area and one in a small city. We focus on the period since the late 1970s that captures acceleration in the decline of the industry. By the end of follow-up, all three study plants had closed.

RESULTS

Table 1 presents summary statistics for the study population of all male workers employed in or after 1970 and for the subset with complete work records who had left work by December 31, 1994 when employment records were truncated. In the entire cohort of 26 804 men, there were 257 deaths due to suicide (n=202) or overdose (n=55). Plant 2 accounted for 38% of the workers, 46% of the suicides and 62% of the overdose fatalities. In the subset with complete work records, 43.7% left work at age 55 or older. Of those, almost all (97.8%) had worked more than 10 years and were thus eligible for at least a partial pension. Histograms for the age at death by suicide or overdose (online supplementary figure 1) are presented in the online supplementary data.

Figure 2 presents trends for suicide rates from 1970 to 2015 (figure 2A) and for suicide combined with fatal overdose for the entire cohort (figure 2B). The suicide rate increased from 1970 to 1995 and then dropped slightly and plateaued during the 2000s at just over 20 per 100 000. When suicide was combined with fatal overdose, the rates continued to increase throughout the time period, reaching 35 per 100 000 in 2015. Some of the workers still employed in 1994 continued to work into the 2000s when the plants were downsizing prior to closing down; Plant 1 closed in 2012, Plant 2 in 2010 and Plant 3 in 2014.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Crude rate (per 100 000 person-years) of suicide and the combined outcome of suicide and fatal overdose by calendar year in the full United Autoworkers-General Motors cohort.

Among the 171 suicides with complete work records, all but 21 occurred after worker exit. The adjusted HR was dramatically elevated for those who had left work (table 2). There was a spike in suicides in the year just after exit, and half of the cases among those no longer at work occurred within 5 years (online supplementary figure 2). When cases that occurred within a week of leaving work were reclassified as having occurred while still employed, the HR decreased from 16.1 to 11.3 (table 2).

Table 3 presents results from the second model that contrasted individuals who left work at retirement versus earlier ages. HRs were elevated by 50–90% for groups who exited before age 40. Those who were 30–39 at worker exit had the highest risk of suicide (HR=1.9, 95% CI 1.2 to 3.0). When overdose was included in the outcome, the HR for that group increased to 2.4, and the HR for the youngest group increased from 1.6 (0.9–2.6) to 2.2 (1.3–3.4). The association between younger age and the combined outcome persisted when follow-up was restricted to the 5 years after worker exit: 2.8 (95% CI 1.6 to 5.1) and 2.4 (95% CI 1.2 to 4.9) for those who left work in their 30s and 20s, respectively (online supplementary table 1).

When a penalised spline function of age at worker exit was substituted for the categorical variable in the Cox models, the HRs for both suicide and the combined outcome were highest for those who left work in their mid-30s (online supplementary figure 3). The maximum HR was almost twofold for suicide and 2.5-fold for overdose combined with suicide, relative to those who left work after age 55. The HRs decline as age at worker exit increases from mid-30s to 55 but remain slightly elevated relative to the risk at retirement age.

Among the 9251 men still at work on December 31, 1994, there were 54 additional cases, 31 suicides and 23 fatal overdoses. Although we do not know exactly when those cases with incomplete work records left work, almost all the overdoses occurred in Plant 2 during the years leading up to the closing of that plant in 2010.

DISCUSSION

This study used data from an existing cohort study initially designed to assess the health effects of occupational exposures to examine the implications of leaving work for risk of death by suicide and overdose. Our results suggest that leaving work prior to retirement age was associated with increased risk even when follow-up was restricted to 5 years after worker exit. Few deaths by suicide or overdose occurred while workers were still employed, and most occurred among those who left work before age 55. These results are consistent with sociological studies of the health consequences of worker exit.^{17 27 28} Although we have no data on subsequent employment, the literature suggests that rehire may mitigate the adverse impacts, but does not eliminate the distress.²⁷

These findings are also consistent with recent studies linking conditions of employment with mental health, suicide and overdose mortality. We reported effects of layoffs on mental healthcare usage and injury risk among workers at 30 US plants using a difference-in-differences approach.²⁹ In that study, the increase in the probability of mental health-related prescriptions appeared attributable primarily to opioid use. In an ecologic study leveraging variation in state economic policies over time, a quasi-experimental design was used to examine the impact of minimum wage and earned income tax credit policies on deaths of despair. Causal models suggest that increasing both by 10% would have prevented 1230 suicides annually, but have no impact on drug overdoses.³⁰ Another study found that higher state-wide union density was associated with lower mortality rates for suicide and overdose.³¹ In a study directly relevant to this one, a difference-in-differences approach estimated an association between county-level automobile assembly closures, from 1999 to 2016, and opioid mortality.³²

Of the three study plants, Plant 2 had the highest incidence rate of suicide in this study. This plant was located at the site of Willow Run, a factory in southeastern Michigan renowned for the mass production of fighter planes during World War II.²⁰ Constructed by Ford Motor Company in 1941 to produce the B-24 Liberator heavy bomber, the plant was the largest in the world at the time, employing more than 100 000 workers. Willow Run was sold to GM after a fire in 1953. By 1970, it employed 10 000 workers making automatic transmissions. Plant 2 closed in 2010 as part of GM’s bankruptcy proceedings. In 1970, the population of the surrounding township was 30 000; today it is 20 000. This scenario dramatises the challenges smaller towns face in coping with the decline in manufacturing.

CONCLUSIONS

Michigan autoworkers who left work after 1970 had a higher risk of death from suicide or overdose than those who remained actively employed. Those who left prior to retirement age had higher rates than those who left after, suggesting that leaving work early may increase the risk.