The health effects of economic decline

Government spending, recession, and suicide: evidence from Japan

Backgrounds

Austerity has been shown to have an adverse influence on people’s mental health and suicide rates. Most existing studies have focused on the governments’ reactions to a single event, for example, the Great Recession of 2008.

Methods

This study focused on significant changes in fiscal policy between 2001 and 2014 in Japan. The size of expenditures by national and local governments decreased dramatically between 2001 and 2006 under the neoliberal reform and then increased after the global economic crisis and the Great East Japan Earthquake. Using the data from 47 prefectures between 2001 and 2014, we tested whether more spending by the local governments was associated with a lower suicide rate in their jurisdiction. We also investigated whether this relationship was particularly salient during a more severe recession.

Results

Our analysis revealed that an increase of 1% in the per capita local government expenditures was associated with a decrease of 0.2% in the suicide rates among males and females aged between 40 and 64 and that this correlation was strengthened as the unemployment rate increased, particularly among males.

Conclusions

Government’s reaction to economic crises can either exacerbate or mitigate the negative impact of the economic recession on people’s mental health and suicide rates.

Effect of the Financial Crisis on Socioeconomic Inequalities in Mortality in Small Areas in Seven Spanish Cities

Background: The aim of this study was to analyze the trend in socioeconomic inequalities in mortality in small areas due to several specific causes before (2001–2004, 2005–2008) and during (2009–2012) the economic crisis in seven Spanish cities. Methods: This ecological study of trends, with census tracts as the areas of analysis, was based on three periods. Several causes of death were studied. A socioeconomic deprivation index was calculated for each census tract. For each small area, we estimated standardized mortality ratios, and controlled for their variability using Bayesian models (sSMR). We also estimated the relative risk of mortality according to deprivation in the different cities, periods, and sexes. Results: In general, a similar geographical pattern was found for the socioeconomic deprivation index and sSMR. For men, there was an association in all cities between the deprivation index and all-cause mortality that remained stable over the three periods. For women, there was an association in Barcelona, Granada, and Sevilla between the deprivation index and all-cause mortality in the third period. Patterns by causes of death were more heterogeneous. Conclusions: After the start of the financial crisis, socioeconomic inequalities in total mortality in small areas of Spanish cities remained stable in most cities, although several causes of death showed a different pattern.

Effect of the recent economic crisis on socioeconomic inequalities in mortality in nine urban areas in Europe

OBJECTIVE

To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis.

METHOD

This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms.

RESULTS

We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively.

CONCLUSIONS

Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders.

Is there a link between cardiovascular mortality and economic fluctuations?

Background: Unemployment might affect several risk factors of cardiovascular disease (CVD), which is the leading cause of death globally. The characterisation of the relation between these two phenomena is thus of great significance from a public-health perspective. The main aim of this study was to estimate the association between the unemployment rate and mortality from CVD and from coronary heart disease (CHD). Additional aims were (a) to assess whether the associations are modified by the degree of unemployment protection; (b) to determine the impact of GDP on heart-disease mortality; and (c) to assess the impact of the Great Recession in this context. Methods: We used time-series data for 32 countries spanning the period 1960-2015. We applied two alternative modelling strategies: (a) error correction modelling, provided that the data were co-integrated; and (b) first-difference modelling in the absence of co-integration. Separate models were estimated for each of five welfare state regimes with different levels of unemployment protection. We also performed country-specific ARIMA-analyses. Results: Because the data did not prove to be co-integrated, we applied first-difference modelling. The estimated effect of unemployment and GDP on CVD as well as CHD was statistically insignificant across age and sex groups and across the various welfare state regimes. An interaction term capturing the possible excess effect of unemployment during the Great Recession was also statistically insignificant. Conclusions: Our findings, based on data from predominantly affluent countries, suggest that heart-disease mortality does not respond to economic fluctuations.

[Impact of Great Recession on mental health in Spain. SESPAS Report 2020]

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market.

Trends in grip strength: Age, period, and cohort effects on grip strength in older adults from Germany, Sweden, and Spain

Grip strength is seen as an objective indicator of morbidity and disability. However, empirical knowledge about trends in grip strength remains incomplete. As trends can occur due to effects of aging, time periods and birth cohorts, we used hierarchical age-period-cohort models to estimate and disentangle putative changes in grip strength. To do this, we used population-based data of older adults, aged 50 years and older, from Germany, Sweden, and Spain from the SHARE study (N = 22500) that encompassed multiple waves of first-time respondents. We found that there were contrasting changes for different age groups: Grip strength improved over time periods for the oldest old, whereas it stagnated or even decreased in younger older adults. Importantly, we found strong birth cohort effects on grip strength: In German older adults, birth cohorts in the wake of the Second World War exhibited increasingly reduced grip strength, and in Spanish older adults, the last birth cohort born after 1960 experienced a sharp drop in grip strength. Therefore, while grip strength increased in the oldest old aged 80 years and older, grip strength stagnated or decreased in comparatively younger cohorts, who might thus be at risk to experience more morbidity and disability in the future than previous generations. Future studies should investigate factors that contribute to this trend, the robustness of the observed birth cohort effects, and the generalizability of our results to other indicators of functional health.

Employment relations and dismissal regulations: Does employment legislation protect the health of workers?

Sociologists have long acknowledged that being in a precarious labour market position, whether employed or unemployed, can harm peoples' health. However, scholars have yet to fully investigate the possible contextual, institutional determinants of this relationship. Two institutions that were overlooked in previous empirical studies are the regulations that set minimum compensation for dismissal, severance payments, and entitlements to a period of notice before dismissal, notice periods. These institutions may be important for workers' health as they influence the degree of insecurity that workers are exposed to. Here, we test this hypothesis by examining whether longer notice periods and greater severance payments protect the health of labour market participants, both employed and unemployed. We constructed two cohorts of panel data before and during the European recession using data from 22 countries in the European Union Statistics on Income and Living Conditions (person years = 338,000). We find more generous severance payments significantly reduce the probability that labour market participants, especially the unemployed, will experience declines in self-reported health, with a slightly weaker relationship for longer notice periods.

Is Being Employed Always Better for Mental Wellbeing Than Being Unemployed? Exploring the Role of Gender and Welfare State Regimes during the Economic Crisis

The growth of poor jobs related to economic crisis adds to its increase since the mid-1970s as a result of new forms of flexible employment. In Europe, there is no clear evidence on whether working in a poor-quality job is better for mental wellbeing than being unemployed. The objectives of this study were to compare mental wellbeing between the unemployed and those working in jobs with different quality levels and to examine gender and welfare state differences in Europe. We selected 8324 men and 7496 women from the European Social Survey, 2010. Hierarchical multiple logistic regression models were fitted, separated by sex and country group. No significant differences in mental wellbeing were shown between unemployed-non-active, unemployed-active, and those working in low-quality jobs in either sex. Only men from Conservative countries in low-quality jobs had better mental wellbeing than unemployed (non-active) men. Only having a good-quality job reduced the likelihood of poor mental wellbeing compared with being unemployed (non-active) among men in all countries (except Social-Democratic) and among women in Eastern and Southern European countries. No differences were observed among men or women in Social-Democratic countries, while strong gender differences were found in Conservative and Liberal countries. Our study indicates the need to take job quality into account, in addition to creating jobs during economic crises. The main mechanisms to explain the strong gender and welfare state differences identified could be social protection for unemployed, labor market regulations, and family models.

Reversal of Upward Trends in Mortality During the Great Recession by Employment Status at Baseline in a National Longitudinal Study

Because of the healthy worker effect, mortality rates increased in individuals who were employed and those who were unemployed, and decreased in those economically inactive at baseline in reported studies. To determine if such trends continue during economic recessions, we analyzed mortality rates in Spain before and during the Great Recession in these subgroups. We included 21,933,351 individuals who were employed, unemployed, or inactive in November 2001 and aged 30-64 years in each calendar-year of follow-up (2002-2011). Annual age-adjusted mortality rates were calculated in each group. The annual percentage change in mortality rates adjusted for age and educational level in employed and unemployed persons were also calculated for 2002-2007 and 2008-2011. In employed and unemployed men, mortality rates increased until 2007 and then declined, whereas in employed and unemployed women, mortality rates increased and then stabilized during 2008-2011. The mortality rate among inactive men and women decreased throughout the follow-up. In the employed and the unemployed, the annual percentage change was reversed during 2008-2011 compared with 2002-2007 (-1.2 vs. 3.2 in employed men; -0.3 vs. 4.1 in employed women; -0.8 vs. 2.9 in unemployed men; and -0.6 vs. 1.3 in unemployed women). The upward trends in mortality rates among individuals who were employed or unemployed in 2001 were reversed during the Great Recession (2008-2011).

Social determinants of health and disparities in prenatal care utilization during the Great Recession period 2005-2010

BACKGROUND

Early, regular prenatal care utilization is an important strategy for improving maternal and infant health outcomes. The purpose of this study is to better understand contributing factors to disparate prenatal care utilization outcomes among women of different racial/ethnic and social status groups before, during, and after the Great Recession (December 2007-June 2009).

METHODS

Data from 678,235 Washington (WA) and Florida (FL) birth certificates were linked to community and state characteristic data to carry out cross-sectional pooled time series analyses with institutional review board approval for human subjects' research. Predictors of on-time as compared to late or non-entry to prenatal care utilization (late/no prenatal care utilization) were identified and compared among pregnant women. Also explored was a simulated triadic relationship among time (within recession-related periods), social characteristics, and prenatal care utilization by clustering individual predictors into three scenarios representing low, average, and high degrees of social disadvantage.

RESULTS

Individual and community indicators of need (e.g., maternal Medicaid enrollment, unemployment rate) increased during the Recession. Associations between late/no prenatal care utilization and individual-level characteristics (including disparate associations among race/ethnicity groups) did not shift greatly with young maternal age and having less than a high school education remaining the largest contributors to late/no prenatal care utilization. In contrast, individual maternal enrollment in a supplemental nutrition program for women, infants, and children (WIC) exhibited a protective association against late/no prenatal care utilization. The magnitude of association between community-level partisan voting patterns and expenditures on some maternal child health programs increased in non-beneficial directions. Simulated scenarios show a high combined impact on prenatal care utilization among women who have multiple disadvantages.

CONCLUSIONS

Our findings provide a compelling picture of the important roles that individual characteristics-particularly low education and young age-play in late/no prenatal care utilization among pregnant women. Targeted outreach to individuals with high disadvantage characteristics, particularly those with multiple disadvantages, may help to increase first trimester entry to utilization of prenatal care. Finally, WIC may have played a valuable role in reducing late/no prenatal care utilization, and its effectiveness during the Great Recession as a policy-based approach to reducing late/no prenatal care utilization should be further explored.

Trends in disease mortality before and during the Great Recession in individuals employed in Spain in 2001

BACKGROUND

Previous studies on economic recessions and mortality due to cancer and other chronic diseases have yielded inconsistent findings. We investigated the trend in all-disease mortality and mortality due to several specific diseases before and during the Great Recession of 2008 in individuals who were employed in 2001, at the beginning of follow-up.

METHODS

We follow in a nationwide longitudinal study over 15 million subjects who had a job in Spain in 2001. The analysed outcomes were mortality at ages 25-64 years due to all diseases, cancer and other chronic diseases. We calculated annual mortality rates from 2003 to 2011, and the annual percentage change (APC) in mortality rates during 2003-07 and 2008-11, as well as the effect size, measured by the APC difference between the two periods.

RESULTS

All-disease mortality increased from 2003 to 2007 in both men and women; then, between 2008 and 2011, all-disease mortality decreased in men and reached a plateau in women. In men, the APC in the all-disease mortality rate was 1.6 in 2003-07 and -1.4 in 2008-11 [effect size -3.0, 95% confidence interval (CI) -3.7 to -2.2]; in women it was 2.5 and -0.3 (effect size -2.8, 95% CI -4.2 to -1.3), respectively. Cancer mortality and mortality due to other chronic diseases revealed similar trends.

CONCLUSIONS

In the group of individuals with a job in 2001 the Great Recession reversed or stabilized the upward trend in all-disease mortality.

Health-related quality of life in adult population before and after the onset of financial crisis: the case of Athens, Greece

PURPOSE

Trends of person-oriented indices with respect to the general population have not been adequately investigated. In Athens, two Health Surveys in 2003 and 2016 provide the opportunity to analyze HRQL in the general adult population. The objectives of this study were to investigate changes in HRQL of adults in the broader area of Athens between 2003 and 2016 and their association with certain socio-demographic determinants.

METHODS

We compared participants from pre- and during-crisis cross-sectional surveys. We used data from 982 and 1060 adult residents of Athens from 2003 and 2016 surveys, respectively. Income-related missing data were treated using three alternative methods. Subscale and summary component SF-36 scores were compared with Mann-Whitney tests and linear regression analyses were used to estimate the effect of demographic and socio-economic variables on HRQL before and after the onset of crisis.

RESULTS

The analysis was based on the results of the procedure of handling missing income data as a separate income group and showed that physical component summary score (PCS) has improved and Mental Component Summary score has deteriorated. The most important predictors of HRQL were being widowed and during the crisis not being employed. Additionally, socio-demographic characteristics explained a higher proportion of variance of HRQL after the onset of crisis, especially for PCS.

CONCLUSION

Decline in mental and improvement in physical HRQL were observed between 2003 and 2016. HRQL has been certainly affected by the recession, but it is difficult to estimate the exact impact of the financial crisis on HRQL.

Socioeconomic inequalities in suicide mortality in Barcelona during the economic crisis (2006-2016): a time trend study

OBJECTIVES

This study aimed to analyse trends in socioeconomic inequalities in suicide mortality in Barcelona before and after the start of the economic crisis that started at the end of 2008, including both individual factors and contextual factors of the deceased's neighbourhood of residence.

DESIGN

This is a trend study of three time periods: pre-economic crisis (2006-2008), early crisis (2009-2012) and late crisis (2013-2016).

SETTING

Total Barcelona residents between 2006 and 2016 (≥25 years of age) and death data derived from the Judicial Mortality Registry of Barcelona.

PARTICIPANTS

996 deaths by suicide between 2006 and 2016 were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes were age-standardised suicide mortality rates and the associations (relative and absolute risk) between suicide mortality and individual and contextual characteristics for the three time periods.

RESULTS

From 2006 to 2008, men with a lower educational level were more likely to commit suicide than better educated men (relative risk (RR)=1.46; 95% CI 1.11 to 1.91). This difference disappeared after the onset of the crisis. We found no differences among women. From 2013 to 2016, suicide risk increased among men living in neighbourhoods with higher unemployment levels (RR=1.57; 95% CI 1.09 to 2.25) and among women living in neighbourhoods with a higher proportion of elderly people living alone (RR=2.13; 95% CI 1.15 to 3.93).

CONCLUSIONS

We observed risks for suicide among men living in neighbourhoods of Barcelona with higher unemployment levels and among women living in neighbourhoods with a higher proportion of elderly people living alone. Inequalities in suicide mortality according to educational level tended to disappear during the crisis among men. Thus, it is important to continue to monitor suicide determinants especially in times of economic crisis.

The Great Recession and adverse birth outcomes: Evidence from California, USA

Objectives

Prior studies of the health effects of recessions have shown mixed results. Ecological studies often report a positive relationship between economic downturns and population health while individual-level studies often show that conditions related to recessions are deleterious. Our study examines the spatially and temporally heterogenous effects of the Great Recession (TGR) on adverse birth outcomes, a contemporaneous measure of population health that is highly responsive to changing social conditions.

Methods

We use restricted birth cohort data from California (2004–2012) merged with both county- and tract-level socio-demographic data, to explore birth selectivity and temporal and unemployment effects during TGR on adverse birth outcomes.

Results

We find that gestational exposure – more specifically, second trimester exposure – during or adjacent to the months of TGR was generally deleterious for birth outcomes, more so, in some cases, for mothers with lower levels of education, and that increases in county-level unemployment were generally deleterious for birth outcomes.

Conclusions

Although recessionary effects on population health are problematic and may have far-reaching effects, it appears that these effects may be largely universal, even given potential selective fertility favoring advantaged groups.

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We use restricted data from California to determine the effects of The Great Recession on adverse birth outcomes.

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We find that increases in unemployment are generally harmful to birth outcomes.

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We also find these effects to be largely universal and not differential in disparity populations.

Avoidable, amenable, and preventable mortalities in South Korea, 2000-2017: Age-period-cohort trends and impact on life expectancy at birth

This study aimed to estimate age-period-cohort effects on avoidable mortality and quantify the impact of avoidable mortality changes on life expectancy (LE) at birth in the South Korean population aged 0-74 years. Using death certificate and resident population data from 2000 to 2017, trends in age-standardized avoidable mortality rates were analyzed with joinpoint regression. Intrinsic estimator regression analysis was conducted to estimate age-period-cohort effects on avoidable mortality. Arriaga's method was used to measure the contributions of avoidable causes to changes in LE gaps between adjacent three-year periods by age and avoidable cause of death groups. Avoidable mortality decreased annually by 4.6% between 2000 and 2017. There were strong age and cohort effects and a weak period effect on avoidable mortality. In the overall decreasing trend, avoidable mortality declined less in cohorts born after the 1950-1953 Korean War and economic recession in the 1970s, with further reductions in cohorts born after the 1987 democratic reform and 1997-1998 economic crisis. Avoidable mortality was reduced after implementation of major health policies, but the decrease stagnated during the 2008-2009 financial crisis. Avoidable mortality reduction resulted in LE gains of 3.1 years, which accounted for 80% of total LE gains. Contribution to LE gains by causes of death was the largest for cerebrovascular disease. Major social changes and health policies influenced the avoidable mortality trend through cohort and period effects. Health care and public health policies implemented since the 2000s might have contributed substantially to gains in LE.

The Great Recession and Mental Health in the United States

The full scope of the impact of The Great Recession on individuals' mental health has not been quantified to date. This study aimed to determine whether financial, job-related, and housing impacts experienced by individuals during the recession predicted changes in the occurrence of symptoms of depression, generalized anxiety, panic attacks, and problematic alcohol or other substance use. Longitudinal survey data (n = 2,530 to n = 3,293) were analyzed from the national Midlife in the United States (MIDUS) study collected before (2003-2004) and after (2012-2013) The Great Recession. The population-level trend was towards improvements in mental health over time. However, for individuals each recession impact experienced was associated with long-lasting and transdiagnostic declines in mental health. These relationships were stronger for some sociodemographic groups, suggesting the need for additional support for people who suffer marked losses during recessions and for those without a strong safety net.

Impact of Cardiovascular Disease on Health Insurance Coverage and Healthcare Use under Economic Stress: The National Health and Nutrition Examination Survey, 2003-2012

Objectives

Cardiovascular disease (CVD) has a substantial financial impact on healthcare systems in the US. This study aimed to examine the impact of CVD on health insurance coverage and health service use under economic stress as indicated by the Great Recession in the US (December 2007–June 2009).

Methods

Data of 26,483 adults aged ≥ 20 years from the 2003–2012 National Health and Nutrition Examination Survey were analyzed. There were 9,479 adults assigned to the group “before the Great Recession” (2003–2006), 5,674 adults assigned to “during the Great Recession” (2007–2008), and 11,330 adults assigned to “after the Great Recession” (2009–2012).

Results

Patients with CVD from low-income families were more likely to have health insurance during the recession (OR:1.57, 95% CI: 1.01,2.45). Those participants without CVD, who were from low-income families or < 65 years, were more likely to use the emergency room rather than primary care facilities to gain access to routine healthcare (p < 0.05). Patients with CVD from high-income families were also more likely to use the emergency room (p < 0.05). Patients with CVD but not those without CVD, who reported a high family income or were ≥ 65 years old, were less likely to use mental health services during the recession than before the recession.

Conclusion

Effective strategies need to be developed to promote primary care use among the general adult American population. In addition, use of mental health services among patients with CVD needs to be improved when financial stress occurs.

Drug and Alcohol Abuse: the Role of Economic Insecurity

Objectives: We evaluate the extent to which subjective and objective measures of economic distress account for differences in substance abuse between the mid-1990s and early-2010s. Methods: We use cross-sectional survey data for national samples of Americans aged 25-74 in 1995-96 (N = 3034) and 2011-14 (N = 2598). Using a logit model, we regress dichotomous indicators of drug and alcohol abuse on economic distress. Results: After adjusting for sociodemographic characteristics, the odds of drug abuse in the early-2010s among older individuals (aged 50+) were 2.9 times (95%CI 1.9-4.2) those of the mid-1990s, but there was no statistically significant period difference in drug abuse among younger individuals. Measures of model performance demonstrate that subjective measures of economic distress are better predictors of drug abuse than objective measures. The subjective measures also account for a larger share (26%) of the increase in drug abuse at ages 50+ than the objective measures (6%). We cannot draw clear conclusions regarding alcohol abuse because results are sensitive to specification. Conclusions: The rise in drug abuse among midlife Americans may relate to perceived economic distress that is not captured by standard economic measures.

A shorter working week for everyone: How much paid work is needed for mental health and well-being?

There are predictions that in future rapid technological development could result in a significant shortage of paid work. A possible option currently debated by academics, policy makers, trade unions, employers and mass media, is a shorter working week for everyone. In this context, two important research questions that have not been asked so far are: what is the minimum amount of paid employment needed to deliver some or all of the well-being and mental health benefits that employment has been shown to bring? And what is the optimum number of working hours at which the mental health of workers is at its highest? To answer these questions, this study used the UK Household Longitudinal Study (2009-2018) data from individuals aged between 16 and 64. The analytical sample was 156,734 person-wave observations from 84,993 unique persons of whom 71,113 had two or more measurement times. Fixed effects regressions were applied to examine how changes in work hours were linked to changes in mental well-being within each individual over time. This study found that even a small number of working hours (between one and 8 h a week) generates significant mental health and well-being benefits for previously unemployed or economically inactive individuals. The findings suggest there is no single optimum number of working hours at which well-being and mental health are at their highest - for most groups of workers there was little variation in wellbeing between the lowest (1-8 h) through to the highest (44-48 h) category of working hours. These findings provide important and timely empirical evidence for future of work planning, shorter working week policies and have implications for theorising the future models of organising work in society.

Single transitions and persistence of unemployment are associated with poor health outcomes

Background

Although job loss has been associated with decline in health, the effect of long term unemployment is less clear and under-researched. Furthermore, the impact of an economic recession on this relationship is unclear. We investigated the associations of single transitions and persistence of unemployment with health. We subsequently examined whether these associations are affected by the latest recession, which began in 2008.

Methods

In total, 57,911 participants from the Dutch Health Interview Survey who belonged to the labour force between 2004 and 2014 were included. Based on longitudinal tax registration data, single employment transitions between time point 1 (t1) and time point 2 (t2) and persistent unemployment (i.e. number of years individuals were unemployed) between t1 and time point 5 (t5) were defined. General and mental health, smoking and obesity were assessed at respectively time point 3 (t3) and time point 6 (t6). Logistic regression models were performed and interactions with recession indicators (year, annual gross domestic product estimates and regional unemployment rates) were tested.

Results

Compared with individuals who stayed employed at t1 and t2, the likelihood of poor mental health at the subsequent year was significantly higher in those who became unemployed at t2. Persistent unemployment was associated with poor mental health, especially for those who were persistently unemployed for 5 years. Similar patterns, although less pronounced for smoking, were found for general health and obesity. Indicators of the economic recession did not modify these associations.

Conclusions

Single transitions into unemployment and persistent unemployment are associated with poor mental and general health, obesity, and to a lesser extend smoking. Our study suggests that re-employment might be an important strategy to improve health of unemployed individuals. The relatively extensive Dutch social security system may explain that the economic recession did not modify these associations.

Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Temporary employment, work stress and mental health before and after the Spanish economic recession

PURPOSE

This paper analyses the effects of temporary employment on work stress and mental health before (2006/2007) and during the economic recession (2011/2012), and examines whether the economic recession worsened these two health outcomes.

METHODS

To control for selection bias, propensity scores (PS) are computed separately for salaried men and women using microdata from two cross-sectional health surveys in Spain, considering temporary (treatment group) versus permanent employment (control group). Next, we use difference-in-difference estimators stratifying by age, education level, and regional unemployment differences using PS as weights.

RESULTS

Our results indicate that salaried worker with a temporary labour contract tends to have similar levels of high work stress and poorer mental health (only for men) than permanent ones for both periods. The economic recession does not appear to worsen both outcomes. However, when stratifying the sample, the economic recession is responsible for increasing stress among older temporary workers and male university graduates, without affecting women. Regarding mental health, we only find evidence of a negative impact of the economic recession on male temporary workers with university education.

CONCLUSION

The economic recession has not affected poor mental health, but it has accentuated the adverse effects of work stress among some specific subgroups of male workers. These subgroups require specific preventive and support actions as the Spanish firms have not substantially changed their hiring practices after the recession.

Do the unemployed hit the bottle during economic downturns? An empirical approach for Spain

BACKGROUND

This paper analyses the 2008 economic collapse in Spain with its long-lasting effects. Precisely, the ones associated with lifestyles. Thus, the aim of this paper is to examine to what extent economic downturns affect individual's drinking behavior when focusing on unemployed people.

METHODS

We use discrete-choice models and matching techniques. Data from the National Health Survey for 2006 and 2011-2012 provides a clear picture before and after the 2008 breakdown in Spain.

RESULTS

We find that drinking over the business cycle is a function of individual socio-demographic status. Besides, our empirical findings are consistent with the idea that following the crisis differences between unemployed and non-unemployed fell to at least in accordance with a lower overall consumption of alcoholic beverages.

CONCLUSIONS

Public policy design for drinkers would require both prevention and recovery from alcohol use strategies to be met towards health and labour pillars.

Determinants of the performance of traditional Chinese medicine clinics in Taiwan

The study attempts to investigate the features and determinants of the performance of Taiwanese Traditional Chinese Medicine (TCM) Clinics with data for 4905 TCM clinics over the 1998 to 2012 period. The empirical results from the fixed effects model and the Hausman-Taylor Model with cluster-robust standard errors reveal several interesting findings. First, consumer characteristics such as the frequency of disabling injuries has positive impacts on the volume of medical services provided by TCM clinics. These results imply that people are likely to select TCM as the option for medical treatment when they face the occurrence of physical injury in Taiwan. In addition, the scale measurements for TCM clinics including the numbers of physicians, medical personnel and divisions have significantly positive effects on the performance of TCM clinics, while their survival length also has the same effect. Finally, the global budget system under the NHI plays a key role in suppressing the revenue of TCM clinics through the peer review mechanism.

The Great Recession and Children's Mental Health in Australia

This paper analyzes the effects of “shocks” to community-level unemployment expectations, induced by the onset of the Great Recession, on children’s mental well-being. The Australian experience of the Great Recession represents a unique case study as despite little change in actual unemployment rates, levels of economic uncertainty grew. This affords us the ability to examine the effects of shocks to economic expectations independent of any actual changes to economic conditions. We draw on and link data from multiple sources, including several waves of the Longitudinal Study of Australian Children (2004–2010), a consumer sentiment survey, and data on local economic conditions. Using our purpose-built data set, we estimate difference-in-differences models to identify plausibly causal effects. We find, for boys, there is no detectable effect of community-level unemployment expectations shocks on mental health. For girls, however, there are modest increases in mental health problems and externalizing behaviors, as measured by the Strengths and Difficulties Questionnaire (SDQ). We additionally find no discernible change in mother’s psychological distress as a result of expectations shocks. These results are stable after controlling for actual labor market conditions.

Did psychotropic drug consumption increase during the 2008 financial crisis? A cross-sectional population-based study in Spain

OBJECTIVES AND SETTING

Although psychotropic drugs are used to treat mental health disorders, little evidence analyses the effects the 2008 economic downturn had on psychotropic drug consumption in the case of Spain. We analyse these effects, considering both gender and employment situation.

PARTICIPANTS

We used the microdata from the face-to-face cross-sectional population-based Spanish National Health Survey for two periods: 2006-2007 (n=28 954) and 2011-2012 (n=20 509). Our samples included adults (>15 years old).

METHODS

The response variables are consumption (or not) of antidepressants or sedatives and the explanatory variables are the year of the survey, gender and employment status. Covariates are mental health problems, mental health index General Health Questionnaire (GHQ-12) and self-reported health outcome variables such as self-rated health, chronic diseases, smoking behaviour, sleeping hours, body mass index, physical activity in the workplace, medical visits during the past year, age, region of residence (autonomous communities), educational level, marital status and social class of the reference person. Finally, we include interactions between time period, gender and employment status. We specify random effects logistic regressions and use Bayesian methods for the inference.

RESULTS

The economic crisis did not significantly change the probability of taking antidepressant drugs (OR=0.56, 95% CI 0.18 to 2.56) nor sedatives (OR=1.21, 95% CI 0.26 to 5.49). In general, the probability of consuming antidepressants among men and women decreases, but there are differences depending on employment status. The probability of consuming sedatives also depends on the employment status.

CONCLUSIONS

While the year of the financial crisis is not associated with the consumption of antidepressants nor sedatives, it has widened the gap in consumption differences between men and women. Although antidepressant use dropped, the difference in consumption levels between men and women grew significantly among the retired, and in the case of sedatives, risk of women taking sedatives increased in all groups except students.

The association between socioeconomic status and depression among older adults in Finland, Poland and Spain: A comparative cross-sectional study of distinct measures and pathways

BACKGROUND

Socioeconomic status, as measured by education, occupation or income, is associated with depression. However, data are lacking on the psychosocial, material and behavioral mediators of these associations. We have examined the association of education, occupation and income with depression and the potential mediations using community-based data.

METHODS

A total of 7,966 older adults were interviewed in Finland, Poland and Spain. The differential associations between depression and SES, mediator variables, country of residence and cofounder variables, such as chronic physical conditions, were assessed through logistic regression models. Meditation analyses were carried out using khb method for Stata 13.1.

RESULTS

Education, followed by household income, were the SES indicators most frequently significantly associated with depression. These SES markers, but not occupation, showed an independent effect in this association. Psychosocial factors and loneliness in particular showed the strongest associations with depression among mediator variables. However, material factors and, especially, financial strain had a higher mediating function in the association between SES and depression. Overall, SES markers, chronic conditions and mediation factors were more positive in Finland than in Poland and Spain.

CONCLUSION

Improving psychosocial and material dimensions as well as access to the educational system for older adults might result in a reduction in the prevalence of depression in the general population and particularly among individuals with low SES.

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.

Contribution of the Economic Crisis to the Risk Increase of Poor Mental Health in a Region of Spain

Previous research suggests that the economic crisis can affect mental health. The purpose of this study was to analyse the association of risk of poor mental health with various socioeconomic, demographic, health, quality of life, and social support variables; and to evaluate the contribution of socioeconomic variables most affected by the beginning of the economic crisis (employment situation and income) on the changes in the prevalence of the risk of poor mental health between 2005 and 2010. A study of prevalence evolution in adult population residents of the Valencian Community in the Spanish Mediterranean was conducted. We studied 5781 subjects in 2005 and 3479 in 2010. Logistic regression models have been adjusted to analyse the association between variables. A standardisation procedure was carried out to evaluate which part of the changes in overall prevalence could be attributed to variations in the population structure by age, sex, employment status, and income between the years under study. The prevalence of GHQ+ increased from 2005 to 2010, in both men and women. Several variables were closely associated with the risk of poor mental health (sex, age, country of birth, number of nonmental chronic diseases, social support, disability, cohabitation in couple, employment status, and income). The changes produced as a result of the onset of the economic crisis in income and unemployment (increase in low income and in unemployment rates) contributed to the increase of poor mental health risk. This could confirm the sensitivity of mental health to the economic deterioration caused by the crisis.

Economic Crisis and Amenable Mortality in Spain

Background: Both overall mortality and avoidable mortality have decreased in recent years in most European countries. It has become clear that less privileged socioeconomic groups have an increased risk of death. In 2008, most countries went into a severe economic recession, whose effects on the health of the population are still ongoing. While on the one hand, some evidence associates the economic crisis with positive health outcomes (pro-cyclical effect), on the other hand, some other evidence suggests that the economic crisis may pose serious public health problems (counter-cyclical effect), which has given rise to controversy. Objectives: To describe the evolution of overall mortality and amenable mortality in Spain between 2002⁻2007 (before the economic crisis) and 2008⁻2013 (during the economic crisis), nationally and by province, as well as to analyse trends in the risks of death and their association with indicators of the impact of the crisis. Methods: Ecological study of overall mortality and amenable mortality describing the evolution of the risks of death between 2002⁻2007 and 2008⁻2013. Age Standardised Rates were calculated, as well as their percentage change between periods. The association between percentage changes and provincial indicators of the impact of the crisis was analysed. Amenable mortality was studied both overall and categorised into five groups. Results: Amenable mortality represented 8.25% of overall mortality in 2002⁻2007, and 6.93% in 2008⁻2013. Age Standardised Rates for overall mortality and global amenable mortality generally declined, with the sharpest decline in amenable mortality. Decreases in overall mortality and amenable mortality were directly related to vulnerability indicators. The most significant decreases were registered in ischaemic heart disease, cerebrovascular disease, and other amenable causes. The relationship with vulnerability indices varied from direct (cancer) to inverse (hypertensive disease). Conclusions: Amenable mortality shows a more significant decrease than overall mortality between both study periods, albeit unevenly between provinces causes of death. Higher vulnerability indicators entail greater declines, although this trend varied for different causes. Mortality trends and their relationship with socioeconomic indicators in a situation of crisis must be conducted cautiously, taking into consideration a possible pro-cyclical effect.

Relationship between economic stress factors and stress, anxiety, and depression: Moderating role of social support

The economic crisis had a detrimental impact on the economies of several European countries, namely in Portugal. The literature emphasizes that periods of economic turmoil potentiate the appearance of mental health issues, such as stress, anxiety, and depression, and decrease populations' well-being. The present study, conducted in Portugal, was performed with a sample of 729 individuals, 33.9% males and 66.1% females, with an average age of 36.99 years old. Its' aim was to assess the relationship between economic stress factors (economic hardship, financial threat, and financial well-being) and stress, anxiety, and depression, as well as to test the moderating effect of social support on this relationship. Structural equation modeling (SEM) was used to examine the relationships defined. When comparing the results obtained in the models without and with social support as a moderator, statistically significant differences were observed on the relationships between financial threat and depression and between economic hardship and stress, anxiety, and depression. Regarding the association between financial threat and stress and anxiety, the effect of the economic stressor decreased in the presence of social support, but the differences were not statistically significant. The implications of these results are discussed and strategies to foster social support are proposed.

Effects of the 2008 global financial crisis on population health

We compare the transmission channels through which the 2008 global financial crisis affected health. We find that postponing or skipping visits to the doctor after falling ill and stopping buying regular medication had the strongest negative effects on health, followed by a reduced consumption of staple foods, utilities being cut, being forced to move, and having to sell assets. In comparison, experiencing cuts in TV, phone, and internet services, as well as delaying payments for utilities had relatively weaker negative impacts. In contrast, having a household head or household member lose a job also had negative effects on health status, although this effect was relatively lower. Finally, a reduced flow of remittances had the weakest negative effect.

Economic downturns and infant health

We study the gender-specific impact of macroeconomic conditions around birth on infant health. We use a sample of over 50,000 respondents born between 1950 and 1994 from Lifelines-a cohort and biobank from the northern Netherlands. Our results show that high provincial unemployment rates decrease fertility and lead to a lower birthweight in boys. The negative impact of high unemployment on birthweight is particularly strong for boys born to older mothers and for babies born to smoking mothers.

Real and predicted mortality under health spending constraints in Italy: a time trend analysis through artificial neural networks

BACKGROUND

After 2008 global economic crisis, Italian governments progressively reduced public healthcare financing. Describing the time trend of health outcomes and health expenditure may be helpful for policy makers during the resources' allocation decision making process. The aim of this paper is to analyze the trend of mortality and health spending in Italy and to investigate their correlation in consideration of the funding constraints experienced by the Italian national health system (SSN).

METHODS

We conducted a 20-year time-series study. Secondary data has been extracted from a national, institution based and publicly accessible retrospective database periodically released by the Italian Institute of Statistics. Age standardized all-cause mortality rate (MR) and health spending (Directly Provided Services - DPS, Agreed-Upon Services - TAUS, and private expenditure) were reviewed. Time trend analysis (1995-2014) through OLS and Multilayer Feed-forward Neural Networks (MFNN) models to forecast mortality and spending trend was performed. The association between healthcare expenditure and MR was analyzed through a fixed effect regression model. We then repeated MFNN time trend forecasting analyses on mortality by adding the spending item resulted significantly related with MR in the fixed effect analyses.

RESULTS

DPS and TAUS decreased since 2011. There was a mismatch in mortality rates between real and predicted values. DPS resulted significantly associated to mortality (p < 0.05). In repeated mortality forecasting analysis, predicted MR was found to be lower when considering the pre-constraints health spending trend.

CONCLUSIONS

Between 2011 and 2014, Italian public health spending items showed a reduction when compared to prior years. Spending on services directly provided free of charge appears to be the financial driving force of the Italian public health system. The overall mortality was found to be higher than the predicted trend and this scenario may be partially attributable to the healthcare funding constraints experienced by the SSN.

What Happened to the Employed During the Great Recession? A U.S. Population Study of Net Change in Employee Insecurity, Health, and Organizational Commitment

This study explored the effects of the Great Recession on U.S. workers who remain employed. The first goal was to assess net population change in job and employment insecurity, physical and mental health, and affective organizational commitment. The second goal was to explore job and employment insecurity as parallel mediators of the associations between the Great Recession and the health and affective organizational commitment outcomes. Data came from two national surveys of U.S. workers that occurred before the recession (N = 2,354) and during the recession (N = 2,322). The results show that the recession was associated with a net increase in both job and employment insecurity, though the increase in employment insecurity was 3.4 times larger than the increase in job insecurity. The recession was associated with a net decrease in physical and mental health and affective organizational commitment. Finally, job and employment insecurity partially mediated the association of the recession with physical health and fully mediated its association with mental health. Job insecurity, but not employment insecurity, partially mediated the association of the recession with affective organizational commitment. The results underscore the importance of research that furthers our understanding of how macroeconomic events affect those who remain employed, and that takes a broad view of employee insecurity regarding continuity of employment.

Economic growth and mortality: do social protection policies matter?

Background

In the 20th century, periods of macroeconomic growth have been associated with increases in population mortality. Factors that cause or mitigate this association are not well understood. Evidence suggests that social policy may buffer the deleterious impact of economic growth. We sought to explore associations between changing unemployment (as a proxy for economic change) and trends in mortality over 30 years in the context of varying social protection expenditures.

Methods

We model change in all-cause mortality in 21 OECD (Organization for Economic Cooperation and Development) countries from 1980 to 2010. Data from the Comparative Welfare States Data Set and the WHO Mortality Database were used. A decrease in the unemployment rate was used as a proxy for economic growth and age-adjusted mortality rates as the outcome. Social protection expenditure was measured as percentage of gross domestic product expended.

Results

A 1% decrease in unemployment (i.e. the proxy for economic growth) was associated with a 0.24% increase in the overall mortality rate (95% confidence interval: 0.07;0.42) in countries with no changes in social protection. Reductions in social protection expenditure strengthened this association between unemployment and mortality. The magnitude of the association was diminished over time.

Conclusions

Our results are consistent with the hypothesis that social protection policies that accompany economic growth can mitigate its potential deleterious effects on health. Further research should identify specific policies that are most effective.

The buffering role of the family in the relationship between job loss and self-perceived health: Longitudinal results from Europe, 2004-2011

Unemployment has numerous negative consequences for health, but the family and the welfare state can mitigate these consequences. How the family supports its members and whether and to what extent this interacts with the broader context is still an open question. Our evidence show that job loss is causally linked to significant declines in health for men, but not for women. Yet, the increased risk of poor health is lower for coupled men, especially if the partner is employed. This suggests that both emotional and economic support play a role. Moreover, the family's mitigating role widely varies across different welfare regimes in Europe and it is particularly strong in Southern and Eastern regimes, characterized by "rudimentary" welfare systems and a more traditional family model.

The Great Recession and Immune Function

The Great Recession precipitated unprecedented home foreclosures increases, but documentation of related neighborhood changes and population health is scant. Using the Detroit Neighborhood Health Study (N = 277), we examined associations between neighborhood-level recession indicators and thymic function, a life course immunological health indicator. In covariate-adjusted multilevel models, each 10 percentage point increase in abandoned home prevalence and 1 percentage point increase in 2009 home foreclosures was associated with 1.7-year and 3.3-year increases in thymic aging, respectively. Associations attenuated after adjustment for neighborhood-level social cohesion, suggesting community ties may buffer recession-related immune aging. Effects of neighborhood stressors were strongest in middle-income households, supporting theory of excess vulnerability in this group. Future research should assess whether ongoing foreclosure and blight reduction efforts improve health for residents of recession impacted neighborhoods.

Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Mental health has been included in the UN Sustainable Development Goals. However, uncertainty exists about the extent to which the major social determinants of mental disorders are addressed by these goals. The aim of this study was to develop a conceptual framework for the social determinants of mental disorders that is aligned with the Sustainable Development Goals, to use this framework to systematically review evidence regarding these social determinants, and to identify potential mechanisms and targets for interventions. We did a systematic review of reviews using a conceptual framework comprising demographic, economic, neighbourhood, environmental events, and social and culture domains. We included 289 articles in the final Review. This study sheds new light on how the Sustainable Development Goals are relevant for addressing the social determinants of mental disorders, and how these goals could be optimised to prevent mental disorders.

Does the Length of Disability between Injury and Functional Restoration Program Entry Affect Treatment Outcomes for Patients with Chronic Disabling Occupational Musculoskeletal Disorders?

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p < .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p < .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (>24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

Embracing Comprehensive Mental Health and Social Services Programs to Serve Children Under California's Mental Health Services Act

Authorized under California's Mental Health Services Act (MHSA) of 2004, full service partnership (FSP) programs address social welfare and other human service needs of seriously mentally ill adults and children who are especially socially and economically vulnerable or who are untreated or insufficiently treated. Because FSP enrollment should reflect greater individual and community distress, we investigated whether counties' enrollment of children into FSPs came from mental health system caseloads with higher crisis use, assessed trauma and substance abuse problems; and from counties which had more foster care placement, more child poverty, lower median household incomes and more unemployment. We addressed these questions in 36 counties over 34 quarters after MHSA's onset. Results indicated greater FSP enrollment for children was associated with higher county unemployment and foster care placement rates and with mental health systems which had increasing children's crisis rates over the study period. These findings suggest that underservice and community adversity prompt officials to adopt and make greater use of children's FSP programming, in keeping with MHSA's intensions.

Shifting determinants of health inequalities in unstable times: Portugal as a case study

Background

We explore how health inequalities (HI) changed in Portugal over the last decade, considering it is one of the most unequal European countries and has gone through major economic changes. We describe how inequalities in limitations changed considering different socioeconomic determinants, in order to understand what drove changes in HI.

Methods

We used cross-sectional waves from the European Survey on Income and Living Conditions database to determine how inequalities in health limitations changed between 2004 and 2014 in Portugal in residents aged 16 years and over. We calculated prevalence estimates of limitations and differences between income terciles, the concentration index for each year and its decomposition and multiple logistic regressions to estimate the association between socioeconomic determinants and limitations.

Results

The prevalence of health limitations increased in Portugal since 2004, especially after 2010, from 35 to 47%. But the difference between top and bottom income terciles decreased from 23 to 10 percentage points, as richer people experienced a steeper increase. This was driven by an increase in prevalence among economically active people, who, from 2011 onwards, had more limitations (OR and 95% CI were 2.42 [2.13-2.75] in 2004 and 0.71 [0.65-0.78] in 2014).

Conclusion

These results suggest worsening health in Portugal in the last decade, possibly connected to periods of economic instability. However, absolute HI decreased considerably in the same period. We discuss the possible role of diverse adaptation capacity of socioeconomic groups, and of high emigration rates of young, healthier people, reflecting another side of the 'migrant health effect'.

The Effects of Unemployment and Economic Distress on Depression Symptoms

Introduction:

The financial crisis in Greece had its strongest impact on unemployment, which led to exacerbation of shrinking incomes and depression symptoms.

Aim:

To investigate the combined effects of unemployment and economic distress on the Greek population mental health in times of economic crisis.

Material and methods:

A cross-sectional study was conducted in the Piraeus Manpower Employment Organization (OAED), during September-December 2017, with 21,600 unemployed people records. A random sample was selected among unemployed who attended this entity. A questionnaire was structured including questions on the unemployed’ sociodemographic characteristics, the Index of Personal Economic Distress (IPED), and the CES-D (Center for Epidemiological Studies -Depression) scale. Descriptive and inductive statistics were performed in order to find the statistical significance of differences. Binary logistic regression was realized to investigate the associations of unemployment and economic distress as prognostic factors for the experience of symptoms associated with depression.

Results:

Totally, 130 unemployed participated in the study. 67.7% was female, the mean age was 37.8 years and 47.7% had a secondary educational level. A significant reduction in household monthly income before and after unemployment was observed (p=0.001). The majority of sample was long-term unemployed and 42.3% was short-term. The mean score of IPED was 12, meaning great economic distress. Moreover, based on CES-D score 63.8% of unemployed presented elevated depression and 36.2% no symptoms of depression. Positive correlation was found between the duration of unemployment with IPED (r=0.565) and with CES-D score (r=0.173). The logistic regression showed that the likelihood of expressing depression was influenced by increasing IPED (OR=1.089) and duration of unemployment (OR=1.322).

Conclusions:

The duration of unemployment and economic hardship led to a higher risk of depressive symptoms, thus policy actions must place greater emphasis on providing additional support through the creation of a more adequate and effective integrated social and health care network.

Unemployment, drugs and attitudes among European youth

This paper studies changes in the patterns of drug consumption and attitudes towards drugs in relation to sky-high (youth) unemployment rates brought about by the Great Recession. Our analysis is based on data for 28 European countries that refer to young people. We find that the consumption of cannabis and 'new substances' is positively related to increasing unemployment rates. An increase of 1% in the regional unemployment rate is associated with an increase of 0.7 percentage points in the ratio of young people who state that they have consumed cannabis at some point in time. Our findings also indicate that higher unemployment may be associated with more young people perceiving that access to drugs has become more difficult, particularly access to ecstasy, cocaine and heroin. According to young Europeans, when the economy worsens, anti-drug policies should focus on the reduction of poverty and unemployment, and not on implementing tougher measures against users.

The Cost of Caring: Economic Vulnerability, Serious Emotional Distress, and Poor Health Behaviors Among Paid and Unpaid Family and Friend Caregivers

This study examined differences between paid and unpaid family/friend caregivers to better understand the consumer-driven caregiving workforce. We compared economic vulnerability, unhealthy behavior, and serious emotional distress for 475 paid and 10,500 unpaid family/friend informal caregivers from the 2009 California Health Interview Survey. We then estimated whether caregiver status moderated the relationship between economic vulnerability and health outcomes. Compared to unpaid family/friend caregivers, paid family/friend caregivers had a 27% greater risk ( p = .002) of economic vulnerability. Among all family/friend caregivers, the probabilities of serious emotional distress and unhealthy behaviors increased by >100% and 28% for those with the greatest compared to the least economic vulnerability, and caregiver type did not moderate these relationships. To address economic and health vulnerabilities of paid informal caregivers, policy makers might increase wages in consumer-driven programs. These changes could prove beneficial to both paid informal caregivers and their care recipients, while reducing long-term inefficiencies in consumer-driven programs.

Hazardous alcohol use among patients with schizophrenia and depression

AIMS

The current study aimed to 1) report the prevalence of hazardous alcohol use in an outpatient population among those with schizophrenia and depressive disorders, 2) assess the sociodemographic and clinical correlates of hazardous alcohol use, 3) examine the association of hazardous alcohol use with severity of depression, anxiety and smoking, and 4) assess the association of hazardous alcohol use with quality of life.

METHODS

Three hundred ten outpatients seeking treatment at a tertiary psychiatric institute with a diagnosis of either schizophrenia spectrum disorder or depressive disorder were included in the study. Patients were assessed for hazardous alcohol use using the Alcohol Use Disorders Identification Test. Information on sociodemographic correlates, clinical history, severity of symptoms of depression and anxiety, as well as quality of life (QOL) was collected.

RESULTS

The overall prevalence of hazardous alcohol use among the sample was 12.6%. The prevalence of hazardous alcohol use among patients with depression and schizophrenia was 18.8% and 6.4%, respectively. Compared to those who were students, patients who were gainfully employed or unemployed were more likely to engage in hazardous alcohol use (Odds Ratio (OR) = 5.5 and 7.7, respectively). Patients with depression compared to those with schizophrenia (OR = 11.1) and those who were current smokers compared to those who had never smoked (OR = 14.5) were more likely to engage in hazardous alcohol use. Hazardous alcohol use was associated with lower QOL in the physical health domain (p = 0.002).

CONCLUSION

Given the significant prevalence of hazardous alcohol use in this population, routine screening for hazardous alcohol use and brief interventions could be an effective way of managing this comorbidity. There is a need to develop and evaluate culturally appropriate brief interventions based on patient preference in this setting.

Population health and the economy: Mortality and the Great Recession in Europe

We analyze the evolution of mortality-based health indicators in 27 European countries before and after the start of the Great Recession. We find that in the countries where the crisis has been particularly severe, mortality reductions in 2007-2010 were considerably bigger than in 2004-2007. Panel models adjusted for space-invariant and time-invariant factors show that an increase of 1 percentage point in the national unemployment rate is associated with a reduction of 0.5% (p < .001) in the rate of age-adjusted mortality. The pattern of mortality oscillating procyclically is found for total and sex-specific mortality, cause-specific mortality due to major causes of death, and mortality for ages 30-44 and 75 and over, but not for ages 0-14. Suicides appear increasing when the economy decelerates-countercyclically-but the evidence is weak. Results are robust to using different weights in the regression, applying nonlinear methods for detrending, expanding the sample, and using as business cycle indicator gross domestic product per capita or employment-to-population ratios rather than the unemployment rate. We conclude that in the European experience of the past 20 years, recessions, on average, have beneficial short-term effects on mortality of the adult population.

Health Expenditure and All-Cause Mortality in the 'Galaxy' of Italian Regional Healthcare Systems: A 15-Year Panel Data Analysis

BACKGROUND

The sustainability of healthcare systems is a topic of major interest. During periods of economic instability, policy makers typically reallocate resources and execute linear cuts in different areas of public spending, including healthcare.

OBJECTIVES

The aim of this paper was to examine whether and how per capita public healthcare expenditure (PHE) in the Italian regions was related to the all-cause mortality rate (MR) between 1999 and 2013 and to determine which expenditure item most affected mortality in the short and very short term.

METHODS

We conducted a pooled cross-sectional time series study. Secondary data were extracted from 'Health for All', a database released periodically by the Italian National Institute of Statistics. PHE is subdivided into directly provided services (DPS), pharmaceutical care, general practitioner care, specialist medical care, privately delivered hospital care, other privately delivered medical services, and psychiatric support and rehabilitation. We used a fixed-effects regression to assess the effects of PHE items on the MR after controlling for a number of socioeconomic and supply variables.

RESULTS

Higher spending on DPS was associated with a lower MR. Other expenditure variables were not significantly associated with the MR.

CONCLUSIONS

The results highlight the importance of medical services and goods provided directly by public services (i.e. hospital-based general and specialized wards and offices, emergency departments, etc.). DPS represents the driving force of the system and should be considered a determinant of the health of the Italian population. Our results suggest that the context and financing methods of a healthcare system should be carefully analysed before linear cuts are made or resources are reallocated.