Systematic review of suicide in economic recession

Table 1 Positive Association Studies

Ref.	Countries studied	Study design	Suicide data source	Recession period	Economic indicator(s) used	Findings
Yang[45]	United States	Time series study Multiple regression analysis	Hollinger P.C Violent Deaths in the United States New York: Guild 1987[63]	Not Specified	Gross National Product per capita Unemployment rate	Total suicide rates were significantly and positively associated with increases in gross national product per capita and unemployment rate (P < 0.05 for both) However, total suicide rates were significantly and negatively associated with increases in gross national product with a one year lag (P < 0.05)
Lester et al[47]	United States and Japan	Time series study Pearson correlation analyses and regression analyses	Annual volumes of Vital Statistics of the United States	Not Specified	Change in Gross National Product Unemployment Rate	Increase in unemployment was significantly and positively correlated with increase in suicide rates in both the United States and Japan (P < 0.05 for both). Regression analyses, however, only showed a positive and significant relationship between unemployment and suicide rates in Japan (P < 0.05)
Gavrilova[16]	Russia	Time series study Descriptive statistics	Gokomstat (Russian statistical committee)	1992-1993	Average real earning and consumer prices	Male suicide rate + 61% and Female Suicide Rate + 22% over 1991-1994 Male morality rate (per 100000) 1991: 47.7 1994: 76.9 Female Mortality Rate (per 100000) 1991: 11.6 1994: 13.2
Ruhm[19]	United States	Panel Study Regression analysis	US Census Bureau	Not Specified	Unemployment Rate	Suicide rate predicted to increase by 1.3% for every percentage point increase in unemployment rate (P = 0.05)
Brainerd[21]	22 former Soviet Bloc Countries	Panel study using regression analysis	World Health Organisation “Health For All” Database 2000	1990-1994	Gross national product per capita and employment to population ratio	A $100 increase in GNP per capita predicted a decrease in suicide rate by 0.14% (P > 0.05) to -0.20% (P < 0.01) in males A one percentage point increase in employment to population ratio predicted decreased suicide rates in males by 3% (P < 0.01)
Lester[42]	United States	Panel Study Regression analysis	Statistical Abstract of the United States	Not Specified	Gross state product per capita Female labour force participation	A one percent increase in gross state product per capita was associated with a 0.45% decrease in total state suicide rates and a 0.55% decrease for male suicide rates (P < 0.05 for both)
Kim et al[28]	South Korea	Time Series Study Descriptive statistics and regression analysis	1999 report on cause specific mortality by the South Korean Statistical office	1997-1999	Unemployment rates and GDP	Suicide cases increased for three months after the recession onset, but decreased after this point Estimated excess suicide mortality caused by recession = 5.1 in 1998 and 0.5 in 1999 (P < 0.01 for both estimates)
Gerdtham et al[12]	Sweden	Cohort Study using descriptive statistics and probit regression	Statistic Sweden’s Survey of living conditions	Not specified	Advanced notification of job loss, changes in GDP, deviation from GDP trends unemployment rates, industry capacity utilisation, and industry confidence indicators	A one standard deviation increase in GDP decreased the risk of suicide by 22.7% (P < 0.05) A one standard deviation increase in the confidence indicator reduces suicide risk by 22.3% (P < 0.05). A one standard deviation decrease in the advanced notification of job loss rate, decreased suicide risk by 21.5% (P < 0.05)
Khang et al[15]	South Korea	Time-series Study Descriptive statistics	Death certificates from South Korean Statistical office	1997-2002	Unemployment rate and GDP per capita	Substantial increase in suicide rates post 1997 in males and females, and then a decline in the rate in both sexes until 2000 Age specific male and female suicide rates (per 100000) in 1996 and 1998: 1-14: MF = 0.8 (1996) and 0.8 (1998) 15-34: MF = 13.5 (1996) and 16.5 (1998) 34-65: M = 26.4 (1996) and 44.3 (1998) F = 8.9 (1996) and 11.9 (1998) 65-79: M = 42.4 (1996) and 58.5 (1998) F = 15.8 (1996) and 22.3 (1998)
Tapia Granados[44]	United States	Time series study Regression analysis	Historical Statistics of the United States	Not Specified	Unemployment rates	Suicide rates significantly associated with increases in the rate of change of unemployment rates from 1920-1944 (P < 0.01) and 1920-1996 (P < 0.01)
Granados[20]	Spain	Panel study Regression analysis	Instituto Nacional de Estadística. (National Statistics Institute)	Not specified	National and province level unemployment rates	Suicide rate predicted to increase by 1.28% for every percentage point increase in the unemployment rate (P = 0.05)
Chang et al[27]	27 European Countries 18 American Countries 8 Asian Countries One South African Country	Time series study	World Health Organisation Mortality Database and The Center for Disease Control Online Database (for the United States)	2008-2010	Gross Domestic Product and Unemployment	Overall suicide rates in men rose 3.3% (95%CI: 2.7-3.9) with a rate ratio of 1.033 (95%CI: 1.027-1.039) and an estimated excess mortality of 5124 (95%CI: 4219-6029) that could be attributed to the recession
Garcy et al[13]	Sweden	Time series study Cox regression	Swedish work and mortality database	1993-1996	Unemployment rates	No excess hazard of suicide mortality attributable to unemployment during the recession in men or women, although an excess hazard post-recession (1997-2002) in men (Hazard ratio = 1.43, 95%CI: 1.31-1.56) and women (Hazard ratio = 1.26, 95%CI: 1.04-1.54)
Chan et al[30]	South Korea	Time Series Study Regression analysis	National Statistical office of Korea	January 2009 to December 2010	Unemployment Rates	Between 2009 and 2010, there was a statistically significant positive association (P < 0.001 for most associations) between suicide rates and national unemployment rates in both the employed and unemployed except in employed men and women aged 50-59 and unemployed men aged 30-39
Madianos et al[32]	Greece	Time series study Descriptive statistics correlation and regression analyses	Vital Statistics Bureau of the Hellenic Statistical Authority	2008-2011	Unemployment Rates Debt as a percentage of Gross Domestic Product	Unemployment and debt as percentage of GDP were significantly and positively correlated with suicide rates ρ = + 0.64, P < 0.001 for unemployment, and ρ = +0.47, P < 0.05 for debt as a percentage of GDP In regression models, increases in unemployment and debt as percentage of GDP were significantly associated with increases in suicide rate (P < 0.05 for debt as a percentage of GDP and P < 0.01 for unemployment)
Phillips et al[25]	United States	Panel study Regression analysis	National Center for Health Statistics	2007-2009/2010	Unemployment Rates	Unemployment significantly (P < 0.05) and positively associated with changes in suicide rates but not in the elderly (65+) or young (15-24)
Pompili et al[33]	Italy	Time series analysis Joinpoint regression	Italian Mortality Database	2007-2010	Gross Domestic Product Unemployment rate	2006-2010: Age specific suicide rates increased in working age men (25-64) by 12% (RR = 1.12; 95%CI: 1.04-1.19), but not in older (65-85+) or younger age groups (1-24)
Reeves et al[26]	Europe and North America	Time series study	World Health Organisation Mortality Database and The Center for Disease Control Database	2008-2010 (Europe) 2008-2009 (Canada)	Unemployment rates	Using 2007 as a baseline, the excess suicide mortality attributable to the recession across the United States, Canada and Europe was 10000