The health effects of economic decline

Invited commentary: are there unrealized benefits of unemployment insurance among the employed?

Political statements about the relationship between the economy and health intensify during economic downturns and fade in times of prosperity. Population health researchers share this cyclical interest in that the numbers of peer-reviewed publications on this topic increase during and immediately after recessions. In this issue of the Journal, Cylus et al. (Am J Epidemiol. 2014;180(1):45-52) follow in the "economy and health" research tradition and examine the relationship between US unemployment rates and suicide mortality. Their work makes a novel contribution in that they examine whether generous unemployment insurance benefits attenuate the relationship between economic downturns and suicide mortality in the United States. In this commentary, I assess the internal validity of their analysis, call into question some assumptions of their approach, and place their contribution within the context of the broader literature. I then argue that population-based and individual-based approaches in the "economy and health" field often work in concert to create knowledge and inform policy-makers.

Unemployment insurance and deteriorating self-rated health in 23 European countries

BACKGROUND

The global financial crisis of 2008 is likely to have repercussions on public health in Europe, not least through escalating mass unemployment, fiscal austerity measures and inadequate social protection systems. The purpose of this study is to analyse the role of unemployment insurance for deteriorating self-rated health in the working age population at the onset of the fiscal crisis in Europe.

METHODS

Multilevel logistic conditional change models linking institutional-level data on coverage and income replacement in unemployment insurance to individual-level panel data on self-rated health in 23 European countries at two repeated occasions, 2006 and 2009.

RESULTS

Unemployment insurance significantly reduces transitions into self-rated ill-health and, particularly, programme coverage is important in this respect. Unemployment insurance is also of relevance for the socioeconomic gradients of health at individual level, where programme coverage significantly reduces health risks attached to educational attainment.

CONCLUSIONS

Unemployment insurance mitigated adverse health effects both at individual and country-level during the financial crisis. Due to the centrality of programme coverage, reforms to unemployment insurance should focus on extending the number of insured people in the labour force.

Race, unemployment rate, and chronic mental illness: a 15-year trend analysis

PURPOSE

Before abating, the recession of the first decade of this century doubled the US unemployment rate. High unemployment is conceptualized as a stressor having serious effects on individuals' mental health. Data from surveys administered repeatedly over 15 years (1997-2011) described changes over time in the prevalence of chronic mental illness among US adults. The data allowed us to pinpoint changes characterizing the White majority--but not Black, Hispanic, or Asian minorities--and to ask whether such changes were attributable to economic conditions (measured via national unemployment rates).

METHODS

We combined 1.5 decades' worth of National Health Interview Survey data in one secondary analysis. We took social structural and demographic factors into account and let adjusted probability of chronic mental illness indicate prevalence of chronic mental illness

RESULTS

We observed, as a general trend, that chronic mental illness probability increased as the unemployment rate rose. A greater increase in probability was observed for Blacks than Whites, notably during 2007-2011, the heart of the recession

CONCLUSIONS

Our results confirmed that structural risk posed by the recent recession and by vulnerability to the recession's effects was differentially linked to Blacks. This led to the group's high probability of chronic mental illness, observed even when individual-level social structural and demographic factors were controlled. Future research should specify the particular kinds of vulnerability that created the additional disadvantage experienced by Black respondents.

Do generous unemployment benefit programs reduce suicide rates? A state fixed-effect analysis covering 1968-2008

The recent economic recession has led to increases in suicide, but whether US state unemployment insurance programs ameliorate this association has not been examined. Exploiting US state variations in the generosity of benefit programs between 1968 and 2008, we tested the hypothesis that more generous unemployment benefit programs reduce the impact of economic downturns on suicide. Using state linear fixed-effect models, we found a negative additive interaction between unemployment rates and benefits among the US working-age (20-64 years) population (β = -0.57, 95% confidence interval: -0.86, -0.27; P < 0.001). The finding of a negative additive interaction was robust across multiple model specifications. Our results suggest that the impact of unemployment rates on suicide is offset by the presence of generous state unemployment benefit programs, though estimated effects are small in magnitude.

Assessing the short term health impact of the Great Recession in the European Union: a cross-country panel analysis

BACKGROUND

There are great concerns and some initial country-specific, descriptive evidence about potential adverse health consequences of the recent Great Recession.

METHODS

Using data for 23 European Union countries we examine the short-term impact of macroeconomic decline during the Great Recession on a range of health and health behaviour indicators. We also examine whether the effect differed between countries according to the level of social protection provided.

RESULTS

Overall, during the recent recession, an increase of one percentage point in the standardised unemployment rate has been associated with a statistically significant decrease in the following mortality rates: all-cause-mortality (3.4%), cardiovascular diseases (3.7%), cirrhosis- and chronic liver disease-related mortality (9.2%), motor vehicle accident-related mortality (11.5%), parasitic infection-related mortality (4.1%), but an increase in the suicide rate (34.1%). In general, the effects were more marked in countries with lower levels of social protection, compared to those with higher levels.

CONCLUSIONS

An increase in the unemployment rate during the Great Recession has had a beneficial health effect on average across EU countries, except for suicide mortality. Social protection expenditures appear to help countries "smooth" the health response to a recession, limiting health damage but also forgoing potential health gains that could otherwise result.

The great recession and health spending among uninsured U.S. immigrants: implications for the Affordable Care Act implementation

OBJECTIVE

We study the association between the timing of the Great Recession (GR) and health spending among uninsured adults distinguishing by citizenship/nativity status and time of U.S. residence.

DATA SOURCE

Uninsured U.S. citizens and noncitizens from the 2005-2006 and 2008-2009 Medical Expenditure Panel Survey.

STUDY DESIGN

The probability of reporting any health spending and the natural logarithm of health spending are our main dependent variables. We compare health spending across population categories before/during the GR. Subsequently, we implement two-part regression analyses of total and specific health-spending measures. We predict average health spending before/during the GR with a smearing estimation.

PRINCIPAL FINDINGS

The probability of reporting any spending diminished for recent immigrants compared to citizens during the GR. For those with any spending, recent immigrants reported higher spending during the GR (27 percent). Average reductions in total spending were driven by the decline in the share of the population reporting any spending among citizens and noncitizens.

CONCLUSIONS

Our study findings suggest that recent immigrants could be forgoing essential care, which later translates into higher spending. It portrays the vulnerability of a population that would remain exposed to income shocks, even after the Affordable Care Act (ACA) implementation.

Economic contraction and maternal health behaviors during pregnancy in a national sample of U.S. women

PURPOSE

The purpose of this study was to examine associations between maternal exposure to unexpected economic contraction and health behaviors during pregnancy using methods to account for impacts of economic contraction on selection into pregnancy.

METHODS

Data on health behaviors among 7074 pregnancies in the National Longitudinal Survey of Youth 1979 were linked to monthly unemployment rates in maternal state of residence. The study examined associations between exposure to unexpected economic contraction (higher than expected state-level unemployment) during each trimester of pregnancy and maternal smoking, alcohol use, and gestational weight gain using generalized linear models.

RESULTS

Economic contraction was not associated with maternal smoking or gestational weight gain. Associations between economic contraction and maternal alcohol use differed by maternal race-ethnicity and education. Among black-non-Hispanic women, exposures to economic contraction during the first and second trimester of pregnancy were associated with a 42% (95% confidence interval, 1.08, 1.85) and 33% (95% confidence interval, 1.01, 1.74) increased risk of alcohol use, respectively.

CONCLUSIONS

Findings suggest that exposure to extreme economic contraction during pregnancy may be associated with increased use of alcohol with differences by maternal race-ethnicity and educational attainment. Economic contraction was not associated with other maternal pregnancy behaviors.

Adolescents' psychological health complaints and the economic recession in late 2007: a multilevel study in 31 countries

BACKGROUND

The recent economic recession, which began in 2007, has had a detrimental effect on the health of the adult population, but no study yet has investigated the impact of this downturn on adolescent health. This article uniquely examines the effect of the crisis on adolescents' psychological health complaints in a cross-national comparison.

METHODS

Data came from the World Health Organization collaborative 'Health Behaviour in School-aged Children' study in 2005-06 and 2009-10. We measured change in psychological health complaints from before to during the recession in the context of changing adult and adolescent unemployment rates. Furthermore, we used logistic multilevel regression to model the impact of absolute unemployment in 2010 and its change rate between 2005-06 and 2009-10 on adolescents' psychological health complaints in 2010.

RESULTS

Descriptive results showed that although youth and adult unemployment has increased during the economic crisis, rates of psychological health complaints among adolescents were unaffected in some countries and even decreased in others. Multilevel regression models support this finding and reveal that only youth unemployment in 2010 increased the likelihood of psychological health complaints, whereas its change rate in light of the recession as well as adult unemployment did not relate to levels of psychological health complaints.

CONCLUSION

In contrast to recent findings, our study indicates that the negative shift of the recent recession on the employment market in several countries has not affected adolescents' psychological health complaints. Adolescents' well-being instead seems to be influenced by the current situation on the labour market that shapes their occupational outlook.

Organizational downsizing and depressive symptoms in the European recession: the experience of workers in France, Hungary, Sweden and the United kingdom

Background

Organizational downsizing has become highly common during the global recession of the late 2000s with severe repercussions on employment. We examine whether the severity of the downsizing process is associated with a greater likelihood of depressive symptoms among displaced workers, internally redeployed workers and lay-off survivors.

Methods

A cross-sectional survey involving telephone interviews was carried out in France, Hungary, Sweden and the United Kingdom. The study analyzes data from 758 workers affected by medium- and large-scale downsizing, using multiple logistic regression.

Main Results

Both unemployment and surviving layoffs were significantly associated with depressive symptoms, as compared to reemployment, but the perceived procedural justice of a socially responsible downsizing process considerably mitigated the odds of symptoms. Perception of high versus low justice was assessed along several downsizing dimensions. In the overall sample, chances to have depressive symptoms were significantly reduced if respondents perceived the process as transparent and understandable, fair and unbiased, well planned and democratic; if they trusted the employer’s veracity and agreed with the necessity for downsizing. The burden of symptoms was significantly greater if the process was perceived to be chaotic. We further tested whether perceived justice differently affects the likelihood of depressive symptoms among distinct groups of workers. Findings were that the odds of symptoms largely followed the same patterns of effects across all groups of workers. Redeploying and supporting surplus employees through the career change process–rather than forcing them to become unemployed–makes a substantial difference as to whether they will suffer from depressive symptoms.

Conclusions

While depressive symptoms affect both unemployed and survivors, a just and socially responsible downsizing process is important for the emotional health of workers.

Impact of financial crisis on selected health outcomes in Europe

BACKGROUND

A number of health outcomes were affected by previous financial crises, e.g. suicides, homicides and transport accident mortality. Aim of this study was to analyse the effects of the current financial crisis on selected health outcomes at population level in Europe.

METHODS

A mixed approach of ecologic and time trend design was applied, including correlation analysis. For eight countries, data on the economic situation (unemployment rate and economic growth) and health indicators (overall mortality, suicide and transport accident mortality) was drawn from EUROSTAT database for 2000-10. Spearman's rank correlation was applied to analyse the influence of social protection on the association between exposure and outcome variables.

RESULTS

The financial crisis had no visible effect on overall mortality in any of the eight countries until 2010. Transport accident mortality decreased in all eight countries, in the range of 18% in Portugal to 52% in Slovenia. In contrast, suicide mortality increased in Germany (+5.3%), Portugal (+5.2%), Czech Republic (+7.6%), Slovakia (+22.7%) and Poland (+19.3%). The effect of unemployment on suicide is higher in countries with lower social spending (Spearman's r = -0.83).

DISCUSSION

Clear cause-effect relations could not be established owing to the ecological study design and issues concerning data availability. However, there are clear changes in suicide and transport accident mortality after onset of the crisis, and findings are consistent with previous work. As part of this work, a comprehensive framework was developed, which can be applied to analyse health effects of financial crises in more detail.

The US healthcare workforce and the labor market effect on healthcare spending and health outcomes

The healthcare sector was one of the few sectors of the US economy that created new positions in spite of the recent economic downturn. Economic contractions are associated with worsening morbidity and mortality, declining private health insurance coverage, and budgetary pressure on public health programs. This study examines the causes of healthcare employment growth and workforce composition in the US and evaluates the labor market's impact on healthcare spending and health outcomes. Data are collected for 50 states and the District of Columbia from 1999-2009. Labor market and healthcare workforce data are obtained from the Bureau of Labor Statistics. Mortality and health status data are collected from the Centers for Disease Control and Prevention's Vital Statistics program and Behavioral Risk Factor Surveillance System. Healthcare spending data are derived from the Centers for Medicare and Medicaid Services. Dynamic panel data regression models, with instrumental variables, are used to examine the effect of the labor market on healthcare spending, morbidity, and mortality. Regression analysis is also performed to model the effects of healthcare spending on the healthcare workforce composition. All statistical tests are based on a two-sided [Formula: see text] significance of [Formula: see text] .05. Analyses are performed with STATA and SAS. The labor force participation rate shows a more robust effect on healthcare spending, morbidity, and mortality than the unemployment rate. Study results also show that declining labor force participation negatively impacts overall health status ([Formula: see text] .01), and mortality for males ([Formula: see text] .05) and females ([Formula: see text] .001), aged 16-64. Further, the Medicaid and Medicare spending share increases as labor force participation declines ([Formula: see text] .001); whereas, the private healthcare spending share decreases ([Formula: see text] .001). Public and private healthcare spending also has a differing effect on healthcare occupational employment per 100,000 people. Private healthcare spending positively impacts primary care physician employment ([Formula: see text] .001); whereas, Medicare spending drives up employment of physician assistants, registered nurses, and personal care attendants ([Formula: see text] .001). Medicaid and Medicare spending has a negative effect on surgeon employment ([Formula: see text] .05); the effect of private healthcare spending is positive but not statistically significant. Labor force participation, as opposed to unemployment, is a better proxy for measuring the effect of the economic environment on healthcare spending and health outcomes. Further, during economic contractions, Medicaid and Medicare's share of overall healthcare spending increases with meaningful effects on the configuration of state healthcare workforces and subsequently, provision of care for populations at-risk for worsening morbidity and mortality.

Incorporating chaos and paradox into career development

The complex, unpredictable and globalized nature of the current labor market challenges the assumptions and utility of traditional career development theories, with new approaches needed in order to help workers navigate their career experience. This article highlights the characteristics of globalization and the changing economic, cultural, political and social landscape, and their implications in the world of work. Historical career theories and limitations are detailed, as well as modern approaches that have developed in response to the identified challenges of globalization and subsequent shifts in career development needs. The chaos theory of careers is presented as a comprehensive framework with which to conceptualize career choice and development. Chaos theory embraces the complexity, change and unpredictability that modern workers face, and allows for a more open, flexible, dynamic and creative approach.

Housing instability and alcohol problems during the 2007-2009 US recession: the moderating role of perceived family support

The 2007-2009 US economic recession was marked by unprecedented rates of housing instability and relatively little is known about how this instability impacted alcohol problems. While previous studies have linked homelessness to increased rates of alcohol use and abuse, housing instability during a recession impacts a much larger segment of the population and usually does not result in homelessness. Using a nationally representative sample of US adults, this study examines the association between housing instability during the recession and alcohol outcomes. Additionally, we assess whether this association is moderated by perceived family support. In multivariate negative binomial regressions, both trouble paying the rent/mortgage (vs. stable housing) and lost (vs. stable) housing were associated with experiencing more negative drinking consequences and alcohol dependence symptoms. However, these associations were moderated by perceived family support. In contrast to those with low perceived family support, participants with high perceived family support reported relatively few alcohol problems, irrespective of housing instability. Furthermore, while job loss was strongly associated with alcohol problems in univariate models, no significant associations between job loss and alcohol outcomes were observed in multivariate models that included indicators of housing instability. Findings point to the importance of the informal safety net and suggest that alcohol screening and abuse prevention efforts should be intensified during periods of recession, particularly among those who experience housing instability.

Investigation of the marked and long-standing spatial inhomogeneity of the Hungarian suicide rate: a spatial regression approach

BACKGROUND

In the last century Hungary had astonishingly high suicide rates characterized by marked regional within-country inequalities, a spatial pattern which has been quite stable over time.

AIMS

To explain the above phenomenon at the level of micro-regions (n=175) in the period between 2005 and 2011.

METHODS

Our dependent variable was the age and gender standardized mortality ratio (SMR) for suicide while explanatory variables were factors which are supposed to influence suicide risk, such as measures of religious and political integration, travel time accessibility of psychiatric services, alcohol consumption, unemployment and disability pensionery. When applying the ordinary least squared regression model, the residuals were found to be spatially autocorrelated, which indicates the violation of the assumption on the independence of error terms and - accordingly - the necessity of application of a spatial autoregressive (SAR) model to handle this problem. According to our calculations the SARlag model was a better way (versus the SARerr model) of addressing the problem of spatial autocorrelation, furthermore its substantive meaning is more convenient.

RESULTS

SMR was significantly associated with the "political integration" variable in a negative and with "lack of religious integration" and "disability pensionery" variables in a positive manner. Associations were not significant for the remaining explanatory variables.

LIMITATIONS

Several important psychiatric variables were not available at the level of micro-regions. We conducted our analysis on aggregate data.

CONCLUSION

Our results may draw attention to the relevance and abiding validity of the classic Durkheimian suicide risk factors - such as lack of social integration - apropos of the spatial pattern of Hungarian suicides.

Population health concerns during the United States' Great Recession

BACKGROUND

Associations between economic conditions and health are usually derived from cost-intensive surveys that are intermittently collected with nonspecific measures (i.e., self-rated health).

PURPOSE

This study identified how precise health concerns changed during the U.S. Great Recession analyzing Google search queries to identify the concern by the query content and their prevalence by the query volume.

METHODS

Excess health concerns were estimated during the Great Recession (December 2008 through 2011) by comparing the cumulative difference between observed and expected (based on linear projections from pre-existing trends) query volume for hundreds of individual terms. As performed in 2013, the 100 queries with the greatest excess were ranked and then clustered into themes based on query content.

RESULTS

The specific queries with the greatest relative excess were stomach ulcer symptoms and headache symptoms, respectively, 228% (95% CI=35, 363) and 193% (95% CI=60, 275) greater than expected. Queries typically involved symptomology (i.e., gas symptoms) and diagnostics (i.e., heart monitor) naturally coalescing into themes. Among top themes, headache queries were 41% (95% CI=3, 148); hernia 37% (95% CI=16, 142); chest pain 35% (95% CI=6, 313); and arrhythmia 32% (95% CI=3, 149) greater than expected. Pain was common with back, gastric, joint, and tooth foci, with the latter 19% (95% CI=4, 46) higher. Among just the top 100, there were roughly 205 million excess health concern queries during the Great Recession.

CONCLUSIONS

Google queries indicate that the Great Recession coincided with substantial increases in health concerns, hinting at how population health specifically changed during that time.

Suicide attempt in young people: a signal for long-term health care and social needs

IMPORTANCE

Suicidal behavior has increased since the onset of the global recession, a trend that may have long-term health and social implications.

OBJECTIVE

To test whether suicide attempts among young people signal increased risk for later poor health and social functioning above and beyond a preexisting psychiatric disorder.

DESIGN

We followed up a cohort of young people and assessed multiple aspects of their health and social functioning as they approached midlife. Outcomes among individuals who had self-reported a suicide attempt up through age 24 years (young suicide attempters) were compared with those who reported no attempt through age 24 years (nonattempters). Psychiatric history and social class were controlled for.

SETTING AND PARTICIPANTS

The population-representative Dunedin Multidisciplinary Health and Development Study, which involved 1037 birth cohort members comprising 91 young suicide attempters and 946 nonattempters, 95% of whom were followed up to age 38 years.

MAIN OUTCOMES AND MEASURES

Outcomes were selected to represent significant individual and societal costs: mental health, physical health, harm toward others, and need for support.

RESULTS

As adults approaching midlife, young suicide attempters were significantly more likely to have persistent mental health problems (eg, depression, substance dependence, and additional suicide attempts) compared with nonattempters. They were also more likely to have physical health problems (eg, metabolic syndrome and elevated inflammation). They engaged in more violence (eg, violent crime and intimate partner abuse) and needed more social support (eg, long-term welfare receipt and unemployment). Furthermore, they reported being lonelier and less satisfied with their lives. These associations remained after adjustment for youth psychiatric diagnoses and social class.

CONCLUSIONS AND RELEVANCE

Many young suicide attempters remain vulnerable to costly health and social problems into midlife. As rates of suicidal behavior rise with the continuing global recession, additional suicide prevention efforts and long-term monitoring and after-care services are needed.

Job displacement among single mothers: effects on children's outcomes in young adulthood

Given the recent era of economic upheaval, studying the effects of job displacement has seldom been so timely and consequential. Despite a large literature associating displacement with worker well-being, relatively few studies focus on the effects of parental displacement on child well-being, and fewer still focus on implications for children of single-parent households. Moreover, notwithstanding a large literature on the relationship between single motherhood and children's outcomes, research on intergenerational effects of involuntary employment separations among single mothers is limited. Using 30 years of nationally representative panel data and propensity score matching methods, the authors find significant negative effects of job displacement among single mothers on children's educational attainment and social-psychological well-being in young adulthood. Effects are concentrated among older children and children whose mothers had a low likelihood of displacement, suggesting an important role for social stigma and relative deprivation in the effects of socioeconomic shocks on child well-being.

Adjusting for selection bias in longitudinal analyses using simultaneous equations modeling: the relationship between employment transitions and mental health

BACKGROUND

Effects of labor force participation on mental health can be difficult to discern due to the possibility of selection bias. Previous research typically adjusts for direct selection (reverse causality) but ignores indirect selection (unmeasured confounders).

METHODS

We investigate the relationship between men's employment transitions and mental health using a dynamic simultaneous equations model applied to data from the British Household Panel Survey (1991-2009). Outcome is self-reported distress and anxiety as summed on a 12-point scale. We allow for direct selection by allowing prior mental health to affect both subsequent mental health and employment transitions in the joint model. We adjust for indirect selection by allowing for residual correlation between mental health and employment.

RESULTS

Moving from unemployment to employment was strongly associated with an improvement in mental health, whereas becoming unemployed was detrimental. However, these associations were attenuated by unmeasured confounders. After adjustment for indirect selection, the increased distress and anxiety associated with becoming unemployed decreased from 2.5 (95% confidence interval = 2.2 to 2.7) to 2.2 (2.0 to 2.5). (A change of 2.5 equates to half a standard deviation on the 12-point scale.) The improvement with moving from unemployment to employment was also weakened slightly (from -2.1 [-2.4 to -1.7] to -1.8 [-2.1 to -1.5]).

CONCLUSIONS

There was strong evidence of indirect selection, but less support for direct selection. Nevertheless, the effects on psychological health of transitions between employment and unemployment, and between employment and economic inactivity, remained substantial after adjusting for selection.

Economic loss and alcohol consumption and problems during the 2008 to 2009 U.S. recession

BACKGROUND

There is some evidence that individual-level job loss can lead to greater alcohol consumption and problems. While other forms of economic loss were common during the recent recession, these are rarely investigated in studies of macroeconomic decline. This study examined the relationship between types of economic loss in the 2008 to 2009 recession and alcohol outcomes, and whether this varied by gender and age.

METHODS

Data are from the 2009 to 2010 U.S. National Alcohol Survey (N = 5,382). We used multivariable regression to estimate associations between economic loss and alcohol volume, monthly drunkenness, negative drinking consequences, and alcohol dependence in the overall sample and within gender and age groups (18 to 29, 30 to 49, 50+), controlling for demographic and alcohol history covariates.

RESULTS

In the overall sample, severe economic loss (job or housing loss) was positively associated with negative drinking consequences, alcohol dependence, and (marginally) drunkenness, whereas moderate loss (loss of retirement savings, reduced work hours/wages, or trouble paying the rent/mortgage) was unassociated with alcohol outcomes. Important gender and age differences were observed. Women reporting retirement loss, reduced hours/wages, and job loss consumed 41 to 70% more alcohol than women unaffected by the recession, and men who experienced job loss and housing problems had increased risk for drunkenness, drinking consequences, and dependence. Middle-aged Americans affected by partial or complete job loss and housing problems also had greater risk of drunkenness and alcohol-related problems, and older adults who lost retirement savings drank 42% more alcohol than their peers unaffected by the recession. With the exception of negative drinking consequences, young adult alcohol outcomes were largely unrelated to recessionary loss.

CONCLUSIONS

This study highlights the adverse effects of recession-induced economic losses on alcohol use and problems in demographic subgroups. As men and middle-aged Americans were at risk for multiple, adverse alcohol outcomes, these groups may warrant special alcohol screening and intervention efforts in future macroeconomic crises.

Temporal Trends and Changing Racial/ethnic Disparities in Alcohol Problems: Results from the 2000 to 2010 National Alcohol Surveys

BACKGROUND

Economic conditions and drinking norms have been in considerable flux over the past 10 years. Accordingly, research is needed to evaluate both overall trends in alcohol problems during this period and whether changes within racial/ethnic groups have affected racial/ethnic disparities.

METHODS

We used 3 cross-sectional waves of National Alcohol Survey data (2000, 2005, and 2010) to examine a) temporal trends in alcohol dependence and consequences overall and by race/ethnicity, and b) the effects of temporal changes on racial/ethnic disparities. Analyses involved bivariate tests and multivariate negative binomial regressions testing the effects of race/ethnicity, survey year, and their interaction on problem measures.

RESULTS

Both women and men overall showed significant increases in dependence symptoms in 2010 (vs. 2000); women also reported increases in alcohol-related consequences in 2010 (vs. 2000). (Problem rates were equivalent across 2005 and 2000.) However, increases in problems were most dramatic among Whites, and dependence symptoms actually decreased among Latinos of both genders in 2010. Consequently, the long-standing disparity in dependence between Latino and White men was substantially reduced in 2010. Post-hoc analyses suggested that changes in drinking norms at least partially drove increased problem rates among Whites.

CONCLUSIONS

Results constitute an important contribution to the literature on racial/ethnic disparities in alcohol problems. Findings are not inconsistent with the macroeconomic literature suggesting increases in alcohol problems during economic recession, but the pattern of effects across race/ethnicity and findings regarding norms together suggest, at the least, a revised understanding of how recessions affect drinking patterns and problems.

Are economic recessions at the time of leaving school associated with worse physical functioning in later life?

PURPOSE

To examine whether economic conditions at the time of leaving school or college are associated with physical functioning in later life among cohorts in 11 European countries.

METHODS

Data came from 10,338 participants in the Survey of Health, Ageing and Retirement in Europe (SHARE) aged 50-74 who left school or college between 1956 and 1986. Data on functional limitations, as well as employment, marriage, and fertility retrospective histories were linked to national unemployment rates during the year individuals left school. Models included country-fixed effects and controls for early-life circumstances.

RESULTS

Greater unemployment rates during the school-leaving year were associated with fewer functional limitations at ages 50-74 among men (rate ratio 0.63, 95% confidence interval 0.47-0.83), but more physical functioning limitations among women (rate ratio 1.30, 95% confidence interval 1.13-1.50), particularly among those with (post-)secondary education. Economic conditions at the age of leaving school were associated with several labor market, marriage, fertility, and health behavior outcomes, but controlling for these factors did not attenuate associations. Results were similar in models that controlled for selection into higher education due to measured covariates.

CONCLUSIONS

Worse economic conditions during the school-leaving year predicted better health at later life among men but worse health among women. Both selection and causation mechanisms may explain this association.

Patterns in mortality among people with severe mental disorders across birth cohorts: a register-based study of Denmark and Finland in 1982-2006

Background

Mortality among patients with mental disorders is higher than in general population. By using national longitudinal registers, we studied mortality changes and excess mortality across birth cohorts among people with severe mental disorders in Denmark and Finland.

Methods

A cohort of all patients admitted with a psychiatric disorder in 1982–2006 was followed until death or 31 December 2006. Total mortality rates were calculated for five-year birth cohorts from 1918–1922 until 1983–1987 for people with mental disorder and compared to the mortality rates among the general population.

Results

Mortality among patients with severe mental disorders declined, but patients with mental disorders had a higher mortality than general population in all birth cohorts in both countries. We observed two exceptions to the declining mortality differences. First, the excess mortality stagnated among Finnish men born in 1963–1987, and remained five to six times higher than at ages 15–24 years in general. Second, the excess mortality stagnated for Danish and Finnish women born in 1933–1957, and remained six-fold in Denmark and Finland at ages 45–49 years and seven-fold in Denmark at ages 40–44 years compared to general population.

Conclusions

The mortality gap between people with severe mental disorders and the general population decreased, but there was no improvement for young Finnish men with mental disorders. The Finnish recession in the early 1990s may have adversely affected mortality of adolescent and young adult men with mental disorders. Among women born 1933–1957, the lack of improvement may reflect adverse effects of the era of extensive hospitalisation of people with mental disorders in both countries.

Effects of the economic crisis on smoking prevalence and number of smokers in the USA

OBJECTIVE

Scanty and controversial information is available on the impact of macroeconomic fluctuations on smoking behaviour. No study has quantified the effects of fiscal crises on smoking prevalence. This study aimed to investigate the effects of the 2007-2008 economic crisis on smoking prevalence and number of smokers in the USA.

METHODS

Using data from the repeated Behavioural Risk Factor Surveillance System (BRFSS) surveys in pre-crisis (2005-2007) and post-crisis (2009-2010) periods on a total of 1,981,607 US adults, we separated the expected (after allowance for the demographic growth of the US population, secular smoking prevalence trends and changes in sociodemographic characteristics) from the unexpected (assumed attributable to the economic crisis) changes in the number of smokers across different employment statuses.

RESULTS

Joinpoint regression analysis revealed no significant changes in smoking prevalence trends over the period 2005-2010. The crisis resulted in an increase in the number of smokers in the US by 0.6 million. This is largely due to an unexpected decrease of 1.7 million smokers among employed and an increase of 2.4 million smokers among unemployed individuals, whose smoking prevalence also remains extremely high in the post-crisis period (32.6%).

CONCLUSIONS

The 2008 financial crisis had a weak effect on smoking prevalence. The pro-cyclical relationship (ie, the crisis results in a lower number of smokers) found among the employed is offset by the counter-cyclical relationship (ie, the crisis results in a higher number of smokers) found among unemployed individuals. Public health interventions should specifically target those in unemployment, particularly in hard times.

Community-Wide Job Loss and Teenage Fertility: Evidence From North Carolina

Using North Carolina data for the period 1990–2010, we estimate the effects of economic downturns on the birthrates of 15- to 19-year-olds, using county-level business closings and layoffs as a plausibly exogenous source of variation in the strength of the local economy. We find little effect of job losses on the white teen birthrate. For black teens, however, job losses to 1 % of the working-age population decrease the birthrate by around 2 %. Birth declines start five months after the job loss and then last for more than one year. Linking the timing of job losses and conceptions suggests that black teen births decline because of increased terminations and perhaps also because of changes in prepregnancy behaviors. National data on risk behaviors also provide evidence that black teens reduce sexual activity and increase contraception use in response to job losses. Job losses seven to nine months after conception do not affect teen birthrates, indicating that teens do not anticipate job losses and lending confidence that job losses are “shocks” that can be viewed as quasi-experimental variation. We also find evidence that relatively advantaged black teens disproportionately abort after job losses, implying that the average child born to a black teen in the wake of job loss is relatively more disadvantaged.

The 2008-2009 recession and alcohol outcomes: differential exposure and vulnerability for Black and Latino populations

OBJECTIVE

We examined whether race/ethnicity was related to exposure to acute economic losses in the 2008-2009 recession, even accounting for individual-level and geographic variables, and whether it influenced associations between economic losses and drinking patterns and problems.

METHOD

Data were from the 2010 National Alcohol Survey (N = 5,382). Surveys assessed both severe losses (i.e., job and housing loss) and moderate losses (i.e., reduced hours/pay and trouble paying the rent/mortgage) attributed to the 2008-2009 recession. Alcohol outcomes included total annual volume, monthly drunkenness, drinking consequences, and alcohol dependence (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

RESULTS

Compared with Whites, Blacks reported significantly greater exposure to job loss and trouble paying the rent/mortgage, and Latinos reported greater exposure to all economic losses. However, only Black-White differences were robust in multivariate analyses. Interaction tests suggested that associations between exposure to economic loss and alcohol problems were stronger among Blacks than Whites. Given severe (vs. no) loss, Blacks had about 13 times the odds of both two or more drinking consequences and alcohol dependence, whereas the corresponding odds ratios for Whites were less than 3. Conversely, associations between economic loss and alcohol outcomes were weak and ambiguous among Latinos.

CONCLUSIONS

Results suggest greater exposure to economic loss for both Blacks and Latinos (vs. Whites) and that the Black population may be particularly vulnerable to the negative effects of economic hardship on the development and/or maintenance of alcohol problems. Findings extend the economic literature and signal policy makers and service providers that Blacks and Latinos may be at special risk during economic downturns.

Social and geographical inequalities in suicide in Japan from 1975 through 2005: a census-based longitudinal analysis

Background

Despite advances in our understanding of the countercyclical association between economic contraction and suicide, less is known about the levels of and changes in inequalities in suicide. The authors examined social and geographical inequalities in suicide in Japan from 1975 through 2005.

Methods

Based on quinquennial vital statistics and census data, the authors analyzed the entire population aged 25–64 years. The total number of suicides was 75,840 men and 30,487 women. For each sex, the authors estimated odds ratios (ORs) and 95% credible intervals (CIs) for suicide using multilevel logistic regression models with “cells” (cross-tabulated by age and occupation) at level 1, seven different years at level 2, and 47 prefectures at level 3. Prefecture-level variance was used as an estimate of geographical inequalities in suicide.

Results

Adjusting for age and time-trends, the lowest odds for suicide was observed among production process and related workers (the reference group) in both sexes. The highest OR for men was 2.52 (95% CI: 2.43, 2.61) among service workers, whereas the highest OR for women was 9.24 (95% CI: 7.03, 12.13) among security workers. The degree of occupational inequalities increased among men with a striking change in the pattern. Among women, we observed a steady decline in suicide risk across all occupations, except for administrative and managerial workers and transport and communication workers. After adjusting for individual age, occupation, and time-trends, prefecture-specific ORs ranged from 0.76 (Nara Prefecture) to 1.36 (Akita Prefecture) for men and from 0.79 (Kanagawa Prefecture) to 1.22 (Akita Prefecture) for women. Geographical inequalities have increased primarily among men since 1995.

Conclusions

The present findings demonstrate a striking temporal change in the pattern of social inequalities in suicide among men. Further, geographical inequalities in suicide have considerably increased across 47 prefectures, primarily among men, since 1995.

Mortality following unemployment in Canada, 1991-2001

BACKGROUND

This study describes the association between unemployment and cause-specific mortality for a cohort of working-age Canadians.

METHODS

We conducted a cohort study over an 11-year period among a broadly representative 15% sample of the non-institutionalized population of Canada aged 30-69 at cohort inception in 1991 (888,000 men and 711,600 women who were occupationally active). We used cox proportional hazard models, for six cause of death categories, two consecutive multi-year periods and four age groups, to estimate mortality hazard ratios comparing unemployed to employed men and women.

RESULTS

For persons unemployed at cohort inception, the age-adjusted hazard ratio for all-cause mortality was 1.37 for men (95% confidence interval (CI): 1.32-1.41) and 1.27 for women (95% CI: 1.20-1.35). The age-adjusted hazard ratio for unemployed men and women was elevated for all six causes of death: malignant neoplasms, circulatory diseases, respiratory diseases, alcohol-related diseases, accidents and violence, and all other causes. For unemployed men and women, hazard ratios for all-cause mortality were equivalently elevated in 1991-1996 and 1997-2001. For both men and women, the mortality hazard ratio associated with unemployment attenuated with age.

CONCLUSIONS

Consistent with results reported from other long-duration cohort studies, unemployed men and women in this cohort had an elevated risk of mortality for accidents and violence, as well as for chronic diseases. The persistence of elevated mortality risks over two consecutive multi-year periods suggests that exposure to unemployment in 1991 may have marked persons at risk of cumulative socioeconomic hardship.

Predictors of health behaviors after the economic downturn: a longitudinal study

Economic declines and their associated stress, shortage of financial resources, and changes in available time can impair health behaviors. This study tested the association between change in working hours, change in employment status, and financial strain and health behaviors measured after the 2008 recession after controlling for pre-recession levels of the health behaviors. The moderating influences of demographic factors and pre-recession levels of the health behaviors on the association between change in working hours and employment status and financial strain and the health behaviors were also tested. Participants (N = 3984) were from a longitudinal study of a U.S. Midwestern community-based sample. Regression analyses tested the unique relations between change in hours worked per week, change in employment status, and financial strain and five health behaviors over and above demographic factors and pre-recession levels of the same behavior. Models included predictor by covariate interactions. Participants who reported higher levels of financial strain engaged in lower levels of all but one of the five health behaviors, but there were no significant main effects of a change in the number of hours worked per week or change in employment status. Significant interactions revealed moderation of these relations by demographic characteristics, but findings differed across health behaviors. Financial strain negatively affected engagement in multiple healthy behaviors. Promoting the maintenance of healthy behaviors for disease prevention is an important public health goal during times of economic decline.

Does Unemployment Lead to Greater Alcohol Consumption?

Using panel data from Waves 1 and 2 of the NESARC, we estimate gender-specific effects of changes in employment status on overall alcohol consumption, binge drinking episodes, and a diagnosis of alcohol abuse and/or dependence. We employ various fixed-effects models to address potential bias from unobserved and time-invariant individual heterogeneity. All results show a positive and significant effect of unemployment on drinking behaviors and the findings are robust to numerous sensitivity tests. Perhaps macroeconomic policy decisions intended to stimulate the economy during economic downturns should also consider the avoided personal costs and externalities associated with alcohol misuse.

Major depression in the era of economic crisis: a replication of a cross-sectional study across Greece

BACKGROUND

The study endeavoured to gauge the impact of the current economic crisis on the mental health of the Greek population. Particularly, it explored changes in the prevalence rates of major depression between 2008 and 2011, and its link to financial hardship. Furthermore, the study also identified potential predictors of major depression in 2011.

METHODS

Two nationwide cross-sectional teleophone surveys were conducted in 2008 and 2011 following the same methodology. A random and representative sample of 2.197 and 2.256 people, respectively, participated in the studies. Major depression was assessed with the Structural Clinical Interview, whereas financial strain with the Index of Personal Economic Distress (IPED), an original scale with good psychometric properties.

RESULTS

In 2011, one-month prevalence rate of major depression was found to be 8.2%, as compared to the corresponding rate in 2008, which was 3.3%. Significant increases in prevalence rates were observed for the majority of the population subgroups. A significant association was recorded between major depression and economic hardship. Young people, married persons, individuals with financial distress and people who use medication displayed increased odds of suffering from major depression in 2011.

LIMITATIONS

Participants' responses concerning financial difficulties were not confirmed from collateral accounts. Moreover, the direction of causality between financial hardship and major depression is unclear.

CONCLUSIONS

The impact of the economic crisis on the mental health of the population is pervasive. Services and clinicians should focus on the primary prevention of major depression as well as on its timely recognition and treatment.

Health and the 2008 economic recession: evidence from the United Kingdom

Introduction

The economic recession which began in 2008 has resulted in a substantial increase in unemployment across many countries, including the United Kingdom. Strong association between unemployment and poor health status among individuals is widely recognised. We investigated whether the prevalence of poor health at a population level increased concurrent to the rise in unemployment during the economic recession, and whether the impact on health varied by geographical and socioeconomic circumstances.

Method

Health, demographic and socioeconomic measures on 1.36 million survey responses aged 16–64 were extracted from the Quarterly Labour Force Survey of the United Kingdom, collected every three months, from January 2006 to December 2010. The likelihood of self-reporting poor health status and specific types of health problems (depression, mental illness, cardiovascular and respiratory) across time were estimated separately using logistic regression. Explanatory variables included economic status (International Labour Organization definition), occupational class, age, gender, country of birth, ethnicity, educational qualifications, couple status, household tenure, number of dependents, and geographical region.

Results

Unemployment (age-gender adjusted) rose from 4.5% in January 2008 to 7.1% by September 2009. The reporting of poor health status increased from 25.7% in July 2009 to 29.5% by December 2010. Similar increases were found for cardiovascular and respiratory health problems; not depression or mental illness. The prevalence of poor health status among the unemployed decreased from 28.8% in July 2008, to 24.9% by March 2009; but this was followed by an increase in poor health experienced across all regions and by all socioeconomic groups, including those who remained employed, regardless of their occupational class.

Interpretation

Although our study found no exacerbation of pre-recession health inequalities, the rise in poor health status not only for the unemployed, but also among people who remained employed, regardless of their occupational class, justifies concern voiced among many public health commentators.

Novel surveillance of psychological distress during the great recession

BACKGROUND

Economic stressors have been retrospectively associated with net population increases in nonspecific psychological distress (PD). However, no sentinels exist to evaluate contemporaneous associations. Aggregate Internet search query surveillance was used to monitor population changes in PD around the United States' Great Recession.

METHODS

Monthly PD query trends were compared with unemployment, underemployment, homes in delinquency and foreclosure, median home value or sale prices, and S&P 500 trends for 2004-2010. Time series analyses, where economic indicators predicted PD one to seven months into the future, were performed in 2011.

RESULT

PD queries surpassed 1,000,000 per month, of which 300,000 may be attributable to the Great Recession. A one percentage point increase in mortgage delinquencies and foreclosures was associated with a 16% (95%CI, 9-24) increase in PD queries one-month, and 11% (95%CI, 3-18) four months later, in reference to a pre-Great Recession mean. Unemployment and underemployment had similar associations half and one-quarter the intensity. "Anxiety disorder", "what is depression", "signs of depression", "depression symptoms", and "symptoms of depression" were the queries exhibiting the strongest associations with mortgage delinquencies and foreclosures, unemployment or underemployment. Housing prices and S&P 500 trends were not associated with PD queries.

LIMITATIONS

A non-traditional measure of PD was used. It is unclear if actual clinically significant depression or anxiety increased during the Great Recession. Alternative explanations for strong associations between the Great Recession and PD queries, such as media, were explored and rejected.

CONCLUSIONS

Because the economy is constantly changing, this work not only provides a snapshot of recent associations between the economy and PD queries but also a framework and toolkit for real-time surveillance going forward. Health resources, clinician screening patterns, and policy debate may be informed by changes in PD query trends.

Natural selection in utero induced by mass layoffs: the hCG evidence

Evolutionary theory, when coupled with research from epidemiology, demography, and population endocrinology, suggests that contracting economies affect the fitness and health of human populations via natural selection in utero. We know, for example, that fetal death increases more among males than females when the economy unexpectedly contracts; that unexpected economic contraction predicts low secondary sex ratios; and that males from low sex ratio birth cohorts live, on average, longer than those from high sex ratio cohorts. We also know that low levels of human chorionic gonadotropin (i.e., hCG) measured in the serum of pregnant women predict fetal death. We do not, however, know whether male survivors of conception cohorts subjected to contracting economies exhibit, as theory predicts, higher hCG than those from other cohorts. We show, in 71 monthly conception cohorts including nearly two million California births, that they do. We thereby add to the literature suggesting that the economy, a phenomenon over which we collectively exercise at least some control, affects population health. Our findings imply that the effect arises via natural selection - a mechanism we largely ignore when attempting to explain, or alter, how collective choice affects our biology.

Smoking among construction workers: the nonlinear influence of the economy, cigarette prices, and antismoking sentiment

Little research has been conducted on the influence of macroeconomic environments on smoking among blue-collar workers, a group with high smoking prevalence and that is especially vulnerable to the effects of changing economic circumstances. Using data from 52,418 construction workers in the Tobacco Use Supplement to the United States Current Population Survey, we examined the association of labor market shock, cigarette prices, and state antismoking sentiments with smoking status and average number of cigarettes smoked daily. Data analysis included the use of multiple linear and logistic regressions, which employed the sampling and replicate weights to account for sampling design. Unemployed, American-Indian, lower-educated and lower-income workers had higher smoking rates. Labor market shock had a quadratic association, which was non-significant for smoking status and significant for number of cigarettes. The association of cigarette prices with smoking status became non-significant after adjusting for state-level antismoking sentiment. State-level antismoking sentiment had significant quadratic association with smoking status among employed workers and significant quadratic association with number of cigarettes for all smokers. The study highlights how both workplace-based smoking cessation interventions and antismoking sentiments could further contribute to disparities in smoking by employment status.

Selection against small males in utero: a test of the Wells hypothesis

BACKGROUND

The argument that women in stressful environments spontaneously abort their least fit fetuses enjoys wide dissemination despite the fact that several of its most intuitive predictions remain untested. The literature includes no tests, for example, of the hypothesis that these mechanisms select against small for gestational age (SGA) males.

METHODS

We apply time-series modeling to 4.9 million California male term births to test the hypothesis that the rate of SGA infants in 1096 weekly birth cohorts varies inversely with labor market contraction, a known stressor of contemporary populations.

RESULTS

We find support for the hypothesis that small size becomes less frequent among term male infants when the labor market contracts.

CONCLUSIONS

Our findings contribute to the evidence supporting selection in utero. They also suggest that research into the association between maternal stress and adverse birth outcomes should acknowledge the possibility that fetal loss may affect findings and their interpretation. Strengths of our analyses include the large number and size of our birth cohorts and our control for autocorrelation. Weaknesses include that we, like nearly all researchers in the field, have no direct measure of fetal loss.

Maternal exposure to unexpected economic contraction and birth weight for gestational age

BACKGROUND

The macro-level economy may affect fetal health through maternal behavioral or physiologic responses.

METHODS

We used a multilevel design to examine associations between exposure to state-level unexpected economic contraction during each trimester of gestation and birth weight for gestational age percentile and small for gestational age (SGA), using the National Longitudinal Survey of Youth 1979. We examined differences in observed associations by maternal educational attainment, race/ethnicity, employment status, and poverty status.

RESULTS

Exposure in the first trimester was associated with a 3.7 percentile point decrease in birth weight for gestational age (95% confidence interval [CI] = -6.8 to -0.6). This association appeared stronger for women "keeping house" or with <12 years education. Exposure in the first trimester was also associated with increased odds of SGA (odds ratio = 1.5 [95% CI = 1.1 to 2.1]) and term SGA (odds ratio = 1.6 [95% CI = 1.2 to 2.3]).

CONCLUSIONS

Unexpected economic contraction during early pregnancy may be associated with reduced fetal growth.

Association of returning to work with better health in working-aged adults: a systematic review

OBJECTIVES

We systematically reviewed the literature on the impact of returning to work on health among working-aged adults.

METHODS

We searched 6 electronic databases in 2005. We selected longitudinal studies that documented a transition from unemployment to employment and included a comparison group. Two reviewers independently appraised the retrieved literature for potential relevance and methodological quality.

RESULTS

Eighteen studies met our inclusion criteria, including 1 randomized controlled trial. Fifteen studies revealed a beneficial effect of returning to work on health, either demonstrating a significant improvement in health after reemployment or a significant decline in health attributed to continued unemployment. We also found evidence for health selection, suggesting that poor health interferes with people's ability to go back to work. Some evidence suggested that earlier reemployment may be associated with better health.

CONCLUSIONS

Beneficial health effects of returning to work have been documented in a variety of populations, times, and settings. Return-to-work programs may improve not only financial situations but also health.

Social and geographic inequalities in premature adult mortality in Japan: a multilevel observational study from 1970 to 2005

OBJECTIVES

To examine trends in social and geographic inequalities in all-cause premature adult mortality in Japan.

DESIGN

Observational study of the vital statistics and the census data.

SETTING

Japan.

PARTICIPANTS

Entire population aged 25 years or older and less than 65 years in 1970, 1975, 1980, 1985, 1990, 1995, 2000 and 2005. The total number of decedents was 984 022 and 532 223 in men and women, respectively.

MAIN OUTCOME MEASURES

For each sex, ORs and 95% CIs for mortality were estimated by using multilevel logistic regression models with 'cells' (cross-tabulated by age and occupation) at level 1, 8 years at level 2 and 47 prefectures at level 3. The prefecture-level variance was used as an estimate of geographic inequalities of mortality.

RESULTS

Adjusting for age and time-trends, compared with production process and related workers, ORs ranged from 0.97 (95% CI 0.96 to 0.98) among administrative and managerial workers to 2.22 (95% CI 2.19 to 2.24) among service workers in men. By contrast, in women, the lowest odds for mortality was observed among production process and related workers (reference), while the highest OR was 12.22 (95% CI 11.40 to 13.10) among security workers. The degree of occupational inequality increased in both sexes. Higher occupational groups did not experience reductions in mortality throughout the period and was overtaken by lower occupational groups in the early 1990s, among men. Conditional on individual age and occupation, overall geographic inequalities of mortality were relatively small in both sexes; the ORs ranged from 0.87 (Okinawa) to 1.13 (Aomori) for men and from 0.84 (Kanagawa) to 1.11 (Kagoshima) for women, even though there is a suggestion of increasing inequalities across prefectures since 1995 in both sexes.

CONCLUSIONS

The present findings suggest that both social and geographic inequalities in all-cause mortality have increased in Japan during the last 3 decades.

Psychiatric epidemiological surveys in China 1960-2010: how real is the increase of mental disorders?

PURPOSE OF REVIEW

Community psychiatric epidemiological surveys over the last five decades have revealed a dramatic increase in the prevalence of mental disorders in China. This article summarizes the main surveys and attempts to interpret the increase of prevalence from a methodological perspective.

RECENT FINDINGS

Regional and national surveys conducted in China during 1960-1990 focused on severe mental disorders and revealed very low and stable rates of disorders. By contrast, those performed in the last decade, whether psychiatrists or lay interviewers were used, have shown much higher and more 'reliable' rates comparable to those found in high-income countries. This is especially so for depression and anxiety disorders.

SUMMARY

Given the sociopolitical turmoil that had previously plagued people in China, the dramatic rise in prevalence estimates of mental disorders in recent years cannot be simply interpreted as a substantive deterioration of mental health following rapid social change. Global and local factors that shape research methodology aimed at showing that mental disorders are common may play an important role in the dramatic increase. Future research in China should move beyond descriptive epidemiology. It should also address policy relevant issues in view of the limited resources available for mental health interventions.