Findings in the context of previous research

Consistent with previous studies, we found an adverse effect of the economic recession in male suicide deaths in the general population,^{Reference Stuckler, Basu, Suhrcke, Coutts and McKee4–Reference Chang, Stuckler, Yip and Gunnell5,Reference Barr, Taylor-Robinson, Scott-Samuel, McKee and Stuckler8} but an increase in patient suicide was also evident in our study. In women, studies have shown the incidence of suicide has been largely unchanged post-recession although reports have indicated a rise in self-harm rates.^{Reference Hawton, Bergen, Geulayov, Waters, Ness and Cooper22} Similar to other studies, we found no recession-related trends in suicide rates in women, both in mental health patients and in the general population.^{Reference Stuckler, Basu, Suhrcke, Coutts and McKee4,Reference Chang, Stuckler, Yip and Gunnell5,Reference Barr, Taylor-Robinson, Scott-Samuel, McKee and Stuckler8}

A previous study found a halt in downward trends in suicide rates in England and Wales in 2006 among the 16- to 24-year-olds and a rise among the 35- to 44-year-olds.^{Reference Coope, Gunnell, Hollingworth, Hawton, Kapur and Fearn10} In our study we found a similar halt in patient suicide rates among those aged 16–24 from the third quarter of 2007 to the end of the study period, but there were no changes in suicide trends in those aged 35–44. A rise in suicide deaths in middle-aged men after the onset of the recession has been reported in other studies.^{Reference Eliason and Storrie23} In line with previous literature, we found no recession-related trends in suicide rates among women.

We found the recession-related rise in patient suicide deaths in middle-aged men has been followed by a fall in the most recent years (2012–2016). Our study also found a fall in in-patient deaths post-2008 but this is unlikely to be related to wider economic factors as a continuous fall in in-patient suicide deaths between 2003 and 2011 has previously been shown.^{Reference Hunt, Rahman, While, Windfuhr, Shaw and Appleby24}

Previous English studies have linked a rise in suicide with increases in unemployment,^{Reference Barr, Taylor-Robinson, Scott-Samuel, McKee and Stuckler8} while others have found mixed evidence of an association between suicide and unemployment.^{Reference Saurina, Bragulat, Saez and López-Casasnovas25} We found an increase in the number of patient suicide deaths after the onset of the recession in those who were unemployed in both men and women. However, this rise coincided with a fall in suicide numbers in those who were long-term sick at the time of death. The upward trend in suicides after the beginning of the recession in young adult males may be explained by the difficulties faced in financing education or finding work for the first time.^{Reference Coope, Gunnell, Hollingworth, Hawton, Kapur and Fearn10} In contrast, middle-aged men may be more exposed to the risks associated with financial difficulties through job loss and benefit cuts. Of note, this rise in suicide in unemployed patients alongside a fall in those who were sick long-term could be linked to the introduction of employment and support allowance (ESA) in 2008 – a welfare benefit that replaced incapacity (sickness) benefit, income support and severe disability allowance paid because of a disability or illness.²⁶ A welfare reform report found that re-assessments of those on incapacity benefit resulted in around a quarter of previous claimants not being deemed eligible for ESA.²⁶ This reduction in the number of people receiving sickness-related benefit may account for the fall in the number of suicide deaths in this group. In addition, our finding of a rise in patient suicide deaths post-recession in men with drug dependence/misuse may be related to the effects of the recession increasing psychological stress resulting in increased drug use.^{Reference Nagelhout, Hummet, de Goeij, de Vries, Kaner and Lemmens27}

Strengths and limitations

To our knowledge, this is the first study to examine recession-related trends and characteristics of suicides in a patient population. We were also able to investigate trends in the most recent years to examine the association between suicides and potential economic recovery. Nevertheless, certain limitations need to be highlighted.

First, we examined patient suicides rates using general population estimates as denominators rather than calculating more informed suicide rates from the target population, i.e. people with a mental illness in service contact. We considered using the number of people in contact with secondary mental health services as denominator data from the Mental Health Services Dataset – a routinely collected data-set of service contact.²⁸ However, time periods were not comparable because of changes to the methodology of how these routine service data have been collected – first around 2011 and then again in 2014 and 2016 with the inclusion of other patient groups such as those with intellectual disabilities, and collection of data from independent organisations as well as a general improvement in data quality. These data have changed significantly over time with half a million men in service contact in 2005 rising to over 1.1 m in 2016. When we explored this further in post hoc analysis (details available on request from the authors) we found that the trends in patient suicide we observed in this study are unlikely to simply be as a result of changing levels of contact with mental health services.

Second, the three different time periods on which we examined patient characteristics were based on our joinpoint findings and on generally accepted pre-recession, recession and post-recession periods determined a priori. To account for any possible variation in recession onset or duration, we performed a sensitivity analysis comparing changes in patient characteristics between 2004–2007 to 2008–2012 and 2013–2016 and found no major differences in our results shown in Tables 3 and 4 and supplementary Tables 1 and 2. Third, with our study being ecological and observational, we need to be wary of the ecological fallacy. The aggregate-level findings may not be applicable to individuals. However, our comparison of patient characteristics was an individually based one. Fourth, although this was a national study the findings may not be applicable to other countries with different health systems.

Finally, we relied on clinicians to provide retrospective data on the patients who had died, which may introduce recall bias. However, most of the questionnaire items concerned objective information (such as gender, age, date of death, method of suicide, living circumstances, in-patient or community patient, treatment received, information on last contact) and the majority were completed by frontline clinicians who had seen or treated the patients prior to suicide (around three-quarters of respondents had direct contact with the patient). Some information such as the date of death and method of suicide was also obtained from ONS. NCISH response rates and data completeness are high.¹⁷

Implications

We found that the rise in male suicide deaths around the time of the recession reported in previous studies was also reflected in a clinical population. More recently, we found a fall in male patient suicide since 2012, and this was most marked in the group who experienced the largest recession-related rises in suicide (those aged 45–54). An improved economic outlook as well as better clinical services could have also played a role in this reduction.¹⁷

How might services and clinicians respond to these findings? Mental health service providers should be aware of the potential impact of wider economic factors on their patients who may be among the most vulnerable groups in society. This is particularly pertinent at a time when the UK faces further economic uncertainty as a result of its planned withdrawal from the European Union. Men in midlife and younger men may be most at risk. There has been an increase in the number of people accessing mental health services and it is important that patient safety more generally and suicide prevention in particular remain priorities.²⁸ One of our findings was the fall in suicide among patients in 2012–2016 and this was against an increase in the number of people seen by services. This may be an indication of an increased focus on patient safety in services as a result of the National Suicide Prevention Strategy (2012).²⁹ In addition, measures to tackle drug and alcohol misuse and greater emphasis on support and interventions for people experiencing economic strain, may help reduce the risk of mental illness and suicide at times of an economic recession.^{Reference Moore, Kapur, Hawton, Richards, Metcalfe and Gunnell30} Specific interventions such as job clubs or group cognitive–behavioural treatment might also be of benefit.^{Reference Robinson, Hetrick and Martin31}