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      Mental health outcomes in times of economic recession: a systematic literature review

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          Abstract

          Background

          Countries in recession experience high unemployment rates and a decline in living conditions, which, it has been suggested, negatively influences their populations’ health. The present review examines the recent evidence of the possible association between economic recessions and mental health outcomes.

          Methods

          Literature review of records identified through Medline, PsycINFO, SciELO, and EBSCO Host. Only original research papers, published between 2004 and 2014, peer-reviewed, non-qualitative research, and reporting on associations between economic factors and proxies of mental health were considered.

          Results

          One-hundred-one papers met the inclusion criteria. The evidence was consistent that economic recessions and mediators such as unemployment, income decline, and unmanageable debts are significantly associated with poor mental wellbeing, increased rates of common mental disorders, substance-related disorders, and suicidal behaviours.

          Conclusion

          On the basis of a thorough analysis of the selected investigations, we conclude that periods of economic recession are possibly associated with a higher prevalence of mental health problems, including common mental disorders, substance disorders, and ultimately suicidal behaviour. Most of the research is based on cross-sectional studies, which seriously limits causality inferences. Conclusions are summarised, taking into account international policy recommendations concerning the cost-effective measures that can possibly reduce the occurrence of negative mental health outcomes in populations during periods of economic recession.

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          Most cited references 119

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          Financial crisis, austerity, and health in Europe.

          The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Psychological autopsy studies of suicide: a systematic review.

            The psychological autopsy method offers the most direct technique currently available for examining the relationship between particular antecedents and suicide. This systematic review aimed to examine the results of studies of suicide that used a psychological autopsy method. A computer aided search of MEDLINE, BIDS ISI and PSYCHLIT, supplemented by reports known to the reviewers and reports identified from the reference lists of other retrieved reports. Two investigators systematically and independently examined all reports. Median proportions were determined and population attributable fractions were calculated, where possible, in cases of suicide and controls. One hundred and fifty-four reports were identified, of which 76 met the criteria for inclusion; 54 were case series and 22 were case-control studies. The median proportion of cases with mental disorder was 91% (95 % CI 81-98%) in the case series. In the case-control studies the figure was 90% (88-95%) in the cases and 27% (14-48%) in the controls. Co-morbid mental disorder and substance abuse also preceded suicide in more cases (38%, 19-57%) than controls (6%, 0-13%). The population attributable fraction for mental disorder ranged from 47-74% in the seven studies in which it could be calculated. The effects of particular disorders and sociological variables have been insufficiently studied to draw clear conclusions. The results indicated that mental disorder was the most strongly associated variable of those that have been studied. Further studies should focus on specific disorders and psychosocial factors. Suicide prevention strategies may be most effective if focused on the treatment of mental disorders.
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              The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis.

              There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects. We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007. We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071). Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns. Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).
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                Author and article information

                Contributors
                diana.frasquilho@hbsc.org
                mmatos@fmh.ulisboa.pt
                ferdinand.salonna@upol.cz
                dfguerreiro@campus.ul.pt
                claudia.costa-storti@emcdda.europa.eu
                tania.gaspar@edu.ulusiada.pt
                caldasjm@fcm.unl.pt
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                3 February 2016
                3 February 2016
                2015
                : 16
                Affiliations
                [ ]Medical School, CMDT, Nova University Lisbon, Lisbon, Portugal
                [ ]Faculty of Human Kinetics, ISAMB, University of Lisbon, Lisbon, Portugal
                [ ]Institute of Active Lifestyle, Faculty of Physical Culture, Palacky University Olomouc, Olomouc, Czech Republic
                [ ]Psychiatry Department, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
                [ ]European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
                [ ]Aventura Social/ISAMB, University of Lisbon and Lisbon Lusíada University, Lisbon, Portugal
                [ ]Department of Mental Health, Medical School, Nova University Lisbon, Lisbon, Portugal
                Article
                2720
                10.1186/s12889-016-2720-y
                4741013
                26847554
                © Frasquilho et al. 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Research Article
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                © The Author(s) 2016

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