Suicidal ideation and suicide attempts in Greece during the economic crisis: an update
Authors: Marina Economou, Elias Angelopoulos, Lily E. Peppou, Kyriakos Souliotis, Costas Stefanis
Journal: World Psychiatry (2016)

The current financial crisis has exerted untoward effects on the mental health of the population worldwide, in the form of increasing prevalence rates of affective disorders and suicide1. Greece is among the countries most severely hit by the crisis and has thus attracted global attention with regard to the social and health-related repercussions of the economic downturn. In particular, throughout the years of recession, unemployment rates rocketed from 7.8% in 2008 to 9.6% in 2009, 12.7% in 2010, 17.9% in 2011, 24.5% in 2012, 27.5% in 2013 and 26.5% in 20142. At the same time, the proportion of the population at risk of poverty or social exclusion rose from 28.1% in 2008 to 35.7% in 2013 and 36% in 20143. Nonetheless, the impact of the recession on suicides has been a highly contentious issue in the country. Recently, a 30-year interrupted time series analysis on the influence of austerity- and prosperity-related events on suicide rates in the period 1983-2012 found a rise in total suicides by 35.7% after the introduction of new austerity measures in June 20114. In a similar vein, another ecological study reported an increase in suicides by 35% between 2010 and 2012, with unemployment bearing a strong correlation with suicide mortality especially among working age men5. A series of nationwide surveys conducted by our research team has arrived at similar conclusions, confirming a significant rise in the one-month prevalence of suicidal ideation (from 5.2% in 2009 to 6.7% in 2011) as well as suicide attempt (from 1.1% in 2009 to 1.5% in 2011)6. In the same report, people suffering from major depression, married individuals, people experiencing financial strain, people with low levels of interpersonal trust and individuals with a history of suicide attempt were at elevated odds of manifesting suicidality symptoms6. In this frame, another cross-sectional study was implemented in 2013 in order to monitor the impact of the recession on suicidality as well as to identify at-risk population subgroups. A random and representative sample of 2,188 people participated in the study. Information about the occurrence of major depression, suicidal ideation and suicidal attempt during the past month was assessed with the pertinent modules of the Structured Clinical Interview for DSM-IV Axis Disorders7. Participants' degree of economic hardship was measured by the Index of Personal Economic Distress8, while their levels of interpersonal trust was assessed by the germane questions of the European Social Survey9. Comparative results from surveys demonstrate that one-month prevalence of suicidal ideation has declined in 2013: 2.4% in 2008, 5.2% in 2009, 6.7% in 2011 and 2.6% in 2013 (p<0.05). Similar findings were observed for one-month prevalence of suicidal attempt: 0.6% in 2008, 1.1% in 2009, 1.5% in 2011 and 0.9% in 2013 (p<0.05). Regarding the risk and protective factors for suicidality, a different pattern of results emerges for suicidal ideation and suicidal attempt. The presence of major depression (adjusted OR = 12.35, 95% CI: 6.34-24.08, p<0.01), a previous suicide attempt (adjusted OR = 5.54, 95% CI: 2.19-14.00, p<0.01), unemployment (adjusted OR = 2.55, 95% CI: 1.04-4.34, p<0.05) and economic hardship (adjusted OR = 1.07, 95% CI: 1.01-1.14, p<0.05) were found to increase the odds of manifesting suicidal thoughts. With regard to suicide attempt, the presence of major depression remained the strongest risk factor (adjusted OR = 8.02, 95% CI: 2.67-24.14, p<0.01), followed by previous suicide attempt (adjusted OR = 5.22, 95% CI: 1.44-18.94, p<0.05) and low levels of interpersonal trust (adjusted OR = 3.84, 95% CI: 1.17-5.81, p<0.05). From the above-mentioned results, it is clear that the prevalence of suicidal ideation and suicidal attempt has returned to pre-crisis levels in Greece. This is consistent with the view that suicidal acts may reflect an acute response to an economic crisis10, as evidenced by the surge in suicides after the outset of the recession in South Korea in 1998 and their subsequent decline11. Concerning the risk factors for suicidal ideation and attempt, the differences illustrate the multifaceted nature of suicidality, which is better conceptualized as lying on a spectrum from ideation to act, with different factors playing a prominent role in each step of the spectrum. The presence of major depression and previous suicide attempt increase the odds of manifesting suicidality symptoms throughout the whole spectrum, in line with other studies corroborating their strength of association12, even amid recession. Although suicidality rates have decreased in Greece, depression is still on the rise13 and the socio-economic climate in the country remains unstable. There is imperative need for tailored public health interventions, including labour market and debt relief programmes, as well as for enhancing the social capital of the population14. From the clinical standpoint, timely screening of suicidal history and suicidal symptoms, effective treatment of major depression, and capitalizing upon a patient's social networks should become a priority. Marina Economou1,2, Elias Angelopoulos1,2, Lily E. Peppou1, Kyriakos Souliotis3,4, Costas Stefanis1 1University Mental Health Research Institute, Athens, Greece; 2First Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece; 3Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece; 4Centre for Health Services Research, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National & Kapodistrian University, Athens, Greece