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Socioeconomic Disadvantage and Suicidal Behaviour Report March 2017 Page No SOCIOECONOMIC DISADVANTAGE AND SUICIDAL BEHAVIOUR Full report March 2017 1 CONTENTS Socioeconomic disadvantage and suicidal behaviour report March 2017 Page No. Chapter 1 3 Introduction Chapter 2: Professor Clare Bambra & Dr Joanne Cairns 8 The impact of place on suicidal behaviour Chapter 3: Associate professor David McDaid 32 Socioeconomic disadvantage and suicidal behaviour during times of economic recession and recovery Chapter 4: Dr Elke Heins 69 Social and labour market policies and suicidal behaviour Chapter 5: Professor Rory O’Connor & Dr Olivia Kirtley 94 Socioeconomic disadvantage and suicidal behaviour: psychological factors Chapter 6: Dr Amy Chandler 126 Explaining the relationship between socioeconomic disadvantage, self-harm and suicide: a qualitative synthesis of the accounts of those who have self-harmed Chapter 7: Dr Katherine Smith 152 In their own words: How do people in the UK understand the impacts of socioeconomic disadvantage on their mental health and risk factors for suicide? Chapter 8 175 Conclusions Chapter 9 179 Recommendations Thanks to everyone who has contributed to the development and production of this report. 2 Chapter 1: Introduction Suicide is a public health issue Suicide is a complex and multi-faceted behaviour, resulting from a wide range of genetic, psychological, psychiatric, social, economic and cultural risk factors which interact to increase vulnerability to trauma and adversity in individuals, communities and society as a whole. The socio-ecological model proposed by the World Health Organization (World Health Organization, 2014) identifies several types (or levels) of risk factors: health system (e.g. barriers to accessing care in the health system); societal (e.g. easy access to means of suicide); community (e.g. stresses of acculturation and dislocation); relationship (e.g. lack of connectedness to people); and individual (e.g. previous suicide attempt, mental illness). A public health approach to suicide prevention seeks to reduce suicide risk by addressing factors at all these levels. Recognising the limitations of providing mental health services to people who are experiencing suicidal thoughts or who have engaged in suicidal behaviour (critical though these services are), a public health approach focuses on the importance of primary prevention, i.e. preventing the occurrence of suicidal thoughts or behaviours, and addresses a broad range of protective and risk factors. Socioeconomic disadvantage is a risk factor that has received insufficient attention, even in national suicide prevention strategies and action plans which incorporate a public health perspective. Importance of socioeconomic disadvantage as a determinant of suicidal behaviour The foundation of this report is an extensive investigation of the epidemiological evidence relating to the hypothesis that socioeconomic disadvantage (see box 1 for definition) is one of the major non-psychiatric determinants of suicidal behaviour (see box 2 for definition). 3 Box 1: Definition of socioeconomic disadvantage ‘Socioeconomic disadvantage’ may refer to an individual, group (e.g., family) or community (especially, defined geographically). Being ‘socioeconomically disadvantaged’ means living in a situation of relatively more unfavourable social and economic circumstances than others (individuals, groups or communities) in the same society. Features of socioeconomic disadvantage include low income, unmanageable debt, poor housing conditions, lack of educational qualifications, unemployment, and living in a socioeconomically deprived area. Box 2: Definition of suicidal behaviour ‘Suicidal behaviour’ comprises suicide and attempted suicide, and, in some instances, non-fatal self-harm (NFSH) where death is not the (main or sole) intended outcome. Self-harm (with or without suicidal intent) is a strong predictor of suicide. Once a person has self-harmed, the likelihood that he or she will die by suicide increases 50 to 100 times compared to someone who has never self-harmed. More than 50% of people who die by suicide have previously self-harmed. The weight of empirical evidence points to a significant association between socioeconomic disadvantage and suicidal behaviour. Key findings include: There is a significantly higher risk of suicide among unemployed, compared to employed, people, even after taking into account other possible explanatory factors (‘confounders’). The adverse effects of economic recession on suicide and other mental health outcomes are highlighted in a recent review (Gunnell & Chang, 2016). “Although increases in job loss contribute to this effect, a range of other stressors such as austerity measures, loss of home, debt, strains on relationships, and reductions in mental health services may also contribute. Those who are already vulnerable, such as individuals who are supported by social welfare or who have pre-existing mental health problems are at greatest risk.” There is an inverse relationship between occupational social class and risk of suicide and NFSH: the higher the social class position, the lower the rate of suicidal behaviour. The findings of a systematic review and meta-analysis of studies of suicide by occupation (Milner et al., 2013) suggest a decreasing gradient of risk, with the highest rate among the lowest skilled occupations (e.g., construction workers) and the lowest rate among the second most skilled occupations (e.g., technicians). A European study of socioeconomic inequalities (measured by educational level and housing 4 tenure) in suicide (Lorant et al., 2005) found that, among men, a low level of educational attainment was a risk factor for suicide in eight out of 10 countries. Among women, however, lower educational attainment tended to be protective against suicide. In five out of six countries for which data were available, the risk of suicide was greater among tenants than among house owners, for both men and women. Over half the papers retrieved for a systematic review of socioeconomic characteristics of regions and their suicide rates (Rehkopf & Buka, 2005) reported no significant associations. In analyses which reported statistically significant findings, the majority pointed to an inverse association between socioeconomic disadvantage and suicide: the lower the socioeconomic position, the higher the suicide rate. The findings of a Scottish study (Platt et al., 2007) confirmed that low social class and socioeconomic deprivation are associated with increased suicide risk; and suggest that the influence of individual social class is far stronger than the influence of area-level socioeconomic affluence/deprivation in accounting for suicide-related inequalities. An exceptionally high relative risk of suicide was found among those in the lowest social class living in the most deprived areas (approximately 10 times higher than the risk of suicide among those in the highest social class in the most affluent areas). Explaining the relationship between socioeconomic disadvantage and suicidal behaviour In order to improve understanding of the relationship between socioeconomic disadvantage and suicidal behaviour, Samaritans commissioned leading social scientists to review and extend the existing body of knowledge on this topic, addressing the following key general questions: Why is there a connection between socioeconomic disadvantage and suicidal behaviour? What is it about socioeconomic disadvantage that increases the risk of suicidal behaviour? What can be done about it? (What are the implications of findings for policy, practice and research?) Taking different disciplinary perspectives, the authors provide insights into the mechanisms and processes underlying the relationship between suicidal behaviour and socioeconomic 5 disadvantage, and provide guidance to policy-makers, practitioners and fellow researchers about future directions for the prevention of suicidal behaviour. Listed with their specialisms and their affiliation, the authors are: Professor Clare Bambra, public health, Newcastle University. Dr Joanne-Marie Cairns, public health, Newcastle University. Dr Amy Chandler, sociology, University of Edinburgh. Dr Elke Heins, social policy, University of Edinburgh. Dr Olivia Kirtley, health psychology, University of Glasgow; University of Ghent. Associate professor David McDaid, health economics, London School of Economics. Professor Rory O’Connor, health psychology, University of Glasgow. Dr Katherine Smith, social policy, University of Edinburgh. This report was co-edited by Stephen Platt, Emeritus Professor of Health Policy Research, University of Edinburgh, and Dr Stephanie Stace and Jacqui Morrissey (Samaritans). Structure of the report Following the introductory chapter, there are six main substantive chapters: Chapters 2-4 consider the relationship between socioeconomic disadvantage and suicidal behaviour from a predominantly macro-level and quantitative perspective, focusing on: o geographical location (Bambra & Cairns [chapter 2]), o rapid economic change (McDaid [chapter 3]) and o labour market policies (Heins [chapter 4]). Chapters 5-7 take a predominantly micro-level and/or qualitative perspective, exploring: o psychological processes (Kirtley & O’Connor [chapter 5), o lay understandings of suicidal behaviour relating to socioeconomic disadvantage (Chandler [chapter 6]) and o lay perspectives on the role of socioeconomic deprivation in mental health outcomes, including suicidal behaviour (Smith [chapter 7]). The concluding chapters synthesise
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