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Cause and effect in studies on unemployment, mental health and suicide: a meta-analytic and conceptual review

  • A. Milner (a1), A. Page (a2) and A. D. LaMontagne (a1)



There are ongoing questions about whether unemployment has causal effects on suicide as this relationship may be confounded by past experiences of mental illness. The present review quantified the effects of adjustment for mental health on the relationship between unemployment and suicide. Findings were used to develop and interpret likely causal models of unemployment, mental health and suicide.


A random-effects meta-analysis was conducted on five population-based cohort studies where temporal relationships could be clearly ascertained.


Results of the meta-analysis showed that unemployment was associated with a significantly higher relative risk (RR) of suicide before adjustment for prior mental health [RR 1.58, 95% confidence interval (CI) 1.33–1.83]. After controlling for mental health, the RR of suicide following unemployment was reduced by approximately 37% (RR 1.15, 95% CI 1.00–1.30). Greater exposure to unemployment was associated with higher RR of suicide, and the pooled RR was higher for males than for females.


Plausible interpretations of likely pathways between unemployment and suicide are complex and difficult to validate given the poor delineation of associations over time and analytic rationale for confounder adjustment evident in the revised literature. Future research would be strengthened by explicit articulation of temporal relationships and causal assumptions. This would be complemented by longitudinal study designs suitable to assess potential confounders, mediators and effect modifiers influencing the relationship between unemployment and suicide.


Corresponding author

* Address for correspondence: A. Milner, Ph.D., McCaughey VicHealth Centre for Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Level 5, 207 Bouverie Street, Melbourne, VIC 3010, Australia. (Email:


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Agerbo, E (2003). Unemployment and suicide: is the link always causal? Journal of Epidemiology and Community Health 57, 560561.
Agerbo, E (2005). Effect of psychiatric illness and labour market status on suicide: a healthy worker effect? Journal of Epidemiology and Community Health 59, 598602.
Baron, RM, Kenny, DA (1986). The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 51, 11731182.
Bertolote, JM, Fleischmann, A, De Leo, D, Wasserman, D (2004). Psychiatric diagnoses and suicide: revisiting the evidence. Crisis 25, 147155.
Blakely, TA, Collings, SC, Atkinson, J (2003). Unemployment and suicide. Evidence for a causal association? Journal of Epidemiology and Community Health 57, 594600.
Brown, J, Demou, E, Tristram, MA, Gilmour, H, Sanati, KA, Macdonald, EB (2012). Employment status and health: understanding the health of the economically inactive population in Scotland. BMC Public Health 12, 327.
Butterworth, P, Leach, L, Pirkis, J, Kelaher, M (2012). Poor mental health influences risk and duration of unemployment: a prospective study. Social Psychiatry and Psychiatric Epidemiology 47, 10131021.
Corcoran, P, Arensman, E (2011). Suicide and employment status during Ireland's Celtic Tiger economy. European Journal of Public Health 21, 209214.
Diez-Roux, AV (1998). Bringing context back into epidemiology: variables and fallacies in multilevel analysis. American Jouurnal of Public Health 88, 216222.
Fergusson, DM, Boden, JM, Horwood, LJ (2007). Unemployment and suicidal behavior in a New Zealand birth cohort: a fixed effects regression analysis. Crisis 28, 95101.
Fergusson, DM, Horwood, LJ, Woodward, LJ (2001). Unemployment and psychosocial adjustment in young adults: causation or selection? Social Science and Medicine 53, 305320.
Glymour, MM (2008). Causal diagrams. In Modern Epidemiology, 3rd edn (ed. Rothman, K., Greenland, S. and Lash, T. L.), pp. Lippincott Williams and Wilkins: Philadelphia.
Greenland, S (2003). Quantifying biases in causal models: classical confounding vs collider-stratification bias. Epidemiology 14, 300306.
Harbord, RM, Harris, RJ, Sterne, JA (2009). Updated tests for small-study effects in meta-analyses. Stata Journal 9, 197210.
Hudson, CG (2005). Socioeconomic status and mental illness: tests of the social causation and selection hypotheses. American Journal of Orthopsychiatry 75, 318.
Kaufman, JS, Maclehose, RF, Kaufman, S (2004). A further critique of the analytic strategy of adjusting for covariates to identify biologic mediation. Epidemiologic Perspectives and Innovations 1, 4.
Kraut, A, Walld, R (2003). Influence of lack of full-time employment on attempted suicide in Manitoba, Canada. Scandinavian Journal of Work Environment and Health 29, 1521.
Lewis, G, Sloggett, A (1998). Suicide, deprivation, and unemployment: record linkage study. British Medical Journal 317, 12831386.
Li, CY, Sung, FC (1999). A review of the healthy worker effect in occupational epidemiology. Occupational Medicine (London) 49, 225229.
Li, Z, Page, A, Martin, G, Taylor, R (2011). Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: a systematic review. Social Science and Medicine 72, 608616.
Lundin, A, Hemmingsson, T (2009). Unemployment and suicide. Lancet 374, 270271.
Lundin, A, Lundberg, I, Allebeck, P, Hemmingsson, T (2012). Unemployment and suicide in the Stockholm population: a register-based study on 771,068 men and women. Public Health 126, 371377.
Lundin, A, Lundberg, I, Hallsten, L, Ottosson, J, Hemmingsson, T (2010). Unemployment and mortality – a longitudinal prospective study on selection and causation in 49 321 Swedish middle-aged men. Journal of Epidemiology and Community Health 64, 2228.
Maki, N, Martikainen, P (2012). A register-based study on excess suicide mortality among unemployed men and women during different levels of unemployment in Finland. Journal of Epidemiology and Community Health 66, 302307.
Milner, A, Hjelmeland, H, Arensman, E, De Leo, D (2013 a). Social and environmental factors and suicide mortality: a narrative review of over 200 articles. Sociology Mind 3, 137148.
Milner, A, Page, A, Lamontagne, AD (2012). Duration of unemployment and suicide in Australia over the period 1985–2006: an ecological investigation by sex and age during rising versus declining national unemployment rates. Journal of Epidemiology and Community Health 67, 237244.
Milner, A, Page, A, Lamontagne, AD (2013 b). Long-term unemployment and suicide: a systematic review and meta-analysis. PLOS ONE 8, e51333.
Morrell, S, Taylor, R, Quine, S, Kerr, C, Western, J (1999). A case–control study of employment status and mortality in a cohort of Australian youth. Social Science and Medicine 49, 383392.
Mortensen, PB, Agerbo, E, Erikson, T, Qin, P, Westergaard-Nielsen, N (2000). Psychiatric illness and risk factors for suicide in Denmark. Lancet 355, 912.
Paul, KI, Moser, K (2009). Unemployment impairs mental health: meta-analyses. Journal of Vocational Behavior 74, 264282.
Platt, S (1984). Unemployment and suicidal behaviour: a review of the literature. Social Science and Medicine 19, 93115.
Qin, P, Agerbo, E, Mortensen, PB (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981–1997. American Journal of Psychiatry 160, 765772.
Qin, P, Agerbo, E, Westergard-Nielsen, N, Eriksson, T, Mortensen, PB (2000). Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry 177, 546550.
Roelfs, DJ, Shor, E, Davidson, KW, Schwartz, JE (2011). Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Social Science and Medicine 72, 840854.
Sanderson, S, Tatt, ID, Higgins, JP (2007). Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. International Journal of Epidemiology 36, 666676.
Shah, D (2009). Healthy worker effect phenomenon. Indian Journal of Occupational and Environmental Medicine 13, 7779.
Shrier, I, Platt, R (2008). Reducing bias through directed acyclic graphs. BMC Medical Research Methodology 8, 70.
Weich, S, Lewis, G (1998). Poverty, unemployment, and common mental disorders: population based cohort study. British Medical Journal 317, 115119.
Yoshimasu, K, Kiyohara, C, Miyashita, K (2008). Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies. Environmental Health and Preventative Medicine 13, 243256.
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