Antonio Preti, Paola Miotto Suicide, unemployment and social capital Mental health, society and suicide Death by suicide is the most severe outcome of a mental illness. Self-inflicted injury is common in the course of Major Depression, Schizophrenia, and Personality Disorders associated to drug addiction [11,43]. In a varying percentage of cases, suicide also occurs in diseases with a chronic course leading to invalidity, such as Huntington’s disease, Parkinson’s disease, Disseminated sclerosis and Epilepsy [5,10,41]. Suicide is still one of the major causes of death in the general population, rating third among the young. In many Western countries suicide has substantially risen in the last decades, particularly among young males, with some decline in the most recent years [19,20]. In the past or, at least, since E. Durkheim’s classical formulation, researchers have identified social concauses as risk factors for suicide together with those of a medical nature [7,21,22]. According to Durkheim, the degree of social integration of a country and the related degree of social regulation influence the risk of suicide. The first element, i.e. the degree of social integration, should be conceived as being dependent upon the complex interactions between individuals and their relational networks. The second element, however, is related to how and to what extent an individual’s needs and desires are fulfilled within the habits and laws of a given society. Clearly, both groups of factors interact and are related to macro- and micro-economic scenarios. To explain suicidal behavior, sociological theories emphasize the role of those conditions that disrupt social-life rhythms: economic crisis, unemployment, change in the degree of social cohesion as a consequence of urbanization and immigration [3,22,27,29, 40,47–49]. Unemployment as an effect of economic crisis is thought to play a very strong influence on social order, and it is seen as a cause of the rise in mortality rates due to ‘external causes’, i.e. homicide and suicide, observed in many countries [29,32,49]. The longer the period of unemployment, the higher the suicide rate [39]. Social ties and the risk of suicide Social ties are likely to provide access to resources and emotional support through advice and behavior monitoring. When networks are well integrated and regulated their members seem more protected from self-destructive behavior [13,27]. Participation in communal activities such as being involved in the local church initiatives, for example, was seen to associate to a lower suicide risk [3,27,40]. The church helps develop friendly interactions among its members: these ties are an important source of social support, and are thought to contribute to lowering the risk of suicide [3,27,40]. More intimate bonding, such as family ties, was also repeatedly seen to associate to a lower risk of suicide. In many countries family dissolution rates show a strong positive relationship with suicide rates, which are lower among married people as against single, widowed or divorced people [40,46,48]. Divorcees show suicide rates 3 or 4 times higher than those observed among married people [40]. The dissolution of family ties can cause psychological trauma, and favor the onset of psychiatric disorders and alcoholism (Stack and Wasserman, 1993). However, many cross-ecological studies found divorce to be a significant predictor of the national suicide rate, even when other factors are taken into account: this proves that the dissolution of the family network is a key factor in suicide [3,40,46,48]. Economic factors can influence the risk of suicide as well as social ones. Suicide can be prevented, though being scarcely foreseeable: effective treatments do exist for all the major mental disorders that are known to have a relationship with the risk of suicide [42,44]. In the long term, the patients receiving appropriate treatment show a significantly lower risk to die by suicide [18,42,44]. Access to health care facilities, thus, is a critical factor in the prevention of suicide. However the costs of this care are increasing, and many countries find it extremely difficult to raise the financial covering for mental-health costs [37]. Moreover, the reduced productivity of the people suffering from severe mental disorders has repercussions on the way their families can afford daily-life commitments. Where economic or social support for disabled people and their families (i.e. social services providing for disability compensations) are poor, affording the costs of the illness and getting access to care become increasingly difficult. But a poor economic situation is not simply a consequence of poverty. Societies with high economic inequalities face strong social conflicts too, leading to poorer physical and mental health status of their members at all levels of the social hierarchy [51]. To sum up, the economic level of a society can influence suicidal risk by both influencing the degree of social cohesion and increasing the chance of survival of the individuals that run a biological risk of mental disorder. Unemployment and suicide Negative life events are thought to favor or to precipitate suicide: adverse financial circumstances and social isolation were found to be significant predictors of suicide risk, and evidence among both young and older groups indicates that stressful experiences, such as the loss of a loved one or interpersonal conflict, often precede suicide attempts. Special attention is often paid to the stress caused by working roles, especially when access to such a role is made problematic by economic crisis [29,32,38]. Unemployment, in particular, is thought to be an important risk factor for suicide: individual-level cross-sectional studies have generally found that among suicides, the percentage of jobless people is higher than among the people who died from other causes [15,29]. Many studies point to unemployment being a precipitating, rather than a causative factor in suicidal crisis. Unemployment is thought to contribute to the precipitation of suicide on two levels: by both reducing financial availability – which makes relational networks less supportive – and leading to a loss of the social role and self-esteem conferred by a job [6,30,49]. The link between unemployment and suicide risk, however, is far from being clearly defined. Three pathways from unemployment to suicide were suggested [1,16]. The “vulnerability model” indicates that unemployment, by limiting access to supportive resources, may increase the impact of stressful life events, thus raising the risk of suicide. The “indirect causative model” suggests that unemployment, through the relationship difficulties or financial problems it can provoke, may favor the occurrence of events that, in their turn, precipitate suicide. A third model proposes a non-causal link between unemployment and suicide, both of which could be taken as resulting from a third factor, such as belonging to a disadvantaged social class which, per se, would increase the risk of suicide and unemployment [23]. All these models share a “social causation” process, which supposes that unemployment, whether directly or indirectly, is detrimental to wellbeing and health. A different set of explanations, grouped under the “health selection” hypothesis, asserts that poorer health itself, including poorer mental health, increases the risk of unemployment: thus, a person affected by a disorder implying a higher risk of suicide would also be prone to unemployment [9]. According to this interpretation of existing data, many people at risk of suicide are unemployed because of their illness, and so higher suicide rates among the unemployed would derive from a selection bias. In fact, high mortality from causes other than suicide is also seen among the unemployed: this excess mortality for all causes of death among the unemployed is often considered to corroborate the “health selection” hypothesis [14,24]. Using data from 1982 to 1994, a period characterized in Italy by an economic crisis with growing unemployment, we found an increase in suicide rates in both sexes [31]. This increase was higher among the unemployed than among the employed; a particularly significant increase was seen among those looking for a first job, with a higher increase in the most recent years, when unemployment was higher (Table I). Becoming and being jobless in a period of high unemployment (such as the latter years of this study period) can be assumed to be less dependant upon the individual’s characteristics, including those that might also confer a higher risk of bad health. It is noteworthy, then, that the unemployed in Italy have been characterized by higher suicide rates in recent years than at the beginning of the study period, when unemployment was lower. Table I. Suicide rates (per 100,000) in Italy by gender and economic position (economically active only), 1982–1994 Year Employed Unemployed In search for 1st job Males Females Males Females Males Females 1982–1983 6.1 1.7 16.8 2.3 5.5 0.7 1993–1994 8.4 2.2 34.3 4.2 35.1 6.6   The economic status of “unemployed” is linked to a higher risk of suicide than the one observed among the employed: in our study the risk of suicide was three times higher among unemployed males than among employed men, and about two times higher among unemployed females than employed ones [31]. People looking for a first job suffered the greater increase in suicide rates over the study period: among males, each year total suicide mortality increased by 0.19 deaths per 100,000 among the employed, 1.62 deaths per 100,000 among the unemployed, and by 2.40 deaths per 100,000 among those in search of their first job. The likely age difference between these groups (people seeking for a first job conceivably being younger, on average, than employed people) does not seem to act as a misleading factor, since suicide rates increased with the increase in the age of individuals in the same period in Italy. The rise in unemployment rates among males preceded, and was positively related to, a concurrent rise in suicide rates among females. Taking into account the limitations of ecological analyses, one can speculate that the link between the rise in male unemployment and the increase in the suicide rate among unemployed females may be a reflection of the destructive effect exerted by the economic crisis on the degree of family cohesion. Studies performed in other contexts show that the dissolution of the familial network is particularly closely linked to suicide risk in the female population [3,36,40,46,48]. Unemployment: pathways to suicide The most recent financial-economic turmoil and the current threatening climate of permanent war will have a foreseeable impact on the standard of living, the consequences of which are still to be evaluated. Socio-economic events are known to produce important fluctuations in suicide mortality. Unemployment, in particular, seems related to suicide risk along direct and indirect pathways. The lack of economic independence as a result of unemployment, for example, reduces the possibility of using social and health services appropriately: this may prejudice compliance with curative treatments, contributing to a worsening in the course of a mental disorder. The most disruptive effect of unemployment, however, acts on social ties at both individual and community levels. Measures of social fragmentation, indeed, were found to predict the risk of death by suicide and alcohol-related diseases [50]. Socio-economic variables are likely to strengthen the impact of employment status on suicide. In the USA the lower the socio-economic status, the higher the suicide risk. However unemployment adds to suicide risk independently in both men and women [2,17]. Other recent studies found that exposure to unemployment is related to suicidal ideation and behavior, even when known psycho-social confounding factors and reverse causality are taken into account [8,35]. Unemployment, hence, should be considered a true risk factor for suicide to be aware of. A closer look at the pathways from unemployment to psychological maladjustment and – hence – to suicide could allow define reasonably practicable strategies aimed at preventing the most negative outcomes. Job loss usually contemplates a whole sequence of stressful events, from anticipation of job loss, to job search and training for re-employment, when possible. Exclusion from ordinary living patterns, customs and activities arising from a lack of resources adds independently to the stress caused by job loss, and further increases the risk of depression and subsequent suicide. Moreover, since it implies a contraction of one’s social network and a relevant alteration of daily-life time structure, job loss may lead to lower surveillance which, together with the availability of lethal means, is another key element in suicide, particularly among mentally troubled people. An effort to provide families with adequate information on this topic could be implemented through first-level health resources, i.e. the network of General Practitioners. Unemployment is also a considerable source of social stress leading to increased family tensions, increased isolation from others, and the loss of self-esteem and confidence. Losing one’s job, indeed, implies the loss of social contact and activity, and often leads to the severing of social ties. A well-integrated social network plays an important protective role in maintaining mental health, offering support, guidance and assistance, favoring compliance with medical or psychiatric treatment and offering swift aid in case of a self-destructive act. In a study concerning black American women Nisbet [25] found that black women, though attempting suicide at about the same rate as white women, are less likely to complete suicide primarily by their larger kinship and friendship networks. Again, increasing access to health services and resources might reduce the negative impact of job loss. Multiplying the points of entry to the health network, even using the still unexplored potentiality of Internet, ought to favor access to treatment when necessary. A different set of explanations, grouped under the “health selection” hypothesis, asserts that poorer health by itself, including poorer mental health, increases the risk of unemployment: thus, an individual affected by a disorder that implies a higher risk of suicide would also experience unemployment. Even if this explanation were accepted, providing support and working opportunities to mentally suffering patients would protect them from the risk of suicide. In a 20-year prospective study on a large sample of psychiatric outpatients, unemployment was the most evident social factor impacting on suicide risk together with clinical ones, such as suicide ideation, and major depressive and bipolar disorders [4]. Recent studies also found that losing a job associates to the onset of psychological disorders, but becoming employed associates to a higher chance to recovering from psychological disorders [23]. Whenever possible, therefore, any effort should be done to keep all the patients with a mental disorder employed. Social capital, unemployment and the risk of suicide In the last decade, following the seminal works of Putnam [33,34], more attention has been paid to a particular feature of social networks: their abilities to implement norms of trust and mutual obligation likely to favor reciprocity in social relationships. Such a component of networking has been named ‘social capital’, and it is thought to contribute to the wealth of a nation, alongside with ‘human’ and ‘economic’ capital. Social capital is an emerging asset of the social network, and includes a structural component, i.e. a peculiar organization of relational ties leading to a mutually beneficial relationship, and a cognitive, more relevant, component, which embodies an individual’s proneness to trust the others and to positively relate themselves to others giving some of their personal resources, such as goods, services or relational time, trusting they will get something in return in the future. Such an asset of people’s personality has a likely biological basis [45]. The genetic basis of reciprocal behaviors is, however, hard to determine. A peculiar status called prosopoagnosia (i.e. the inability to recognize people’s faces) originates from lesions in a specific brain section, the parietal-occipital region of the brain. The patients suffering from this lesion are unable to recognize their relatives and friends by looking at their faces, since these people look unknown to them. But when they can listen to their voices or see how they move, if such relatives and friends have any peculiar characteristic in this sense, then they can recognize them. Prosopoagnosia may seem a bizarre oddity, if it weren’t a cause of embarrassment for those affected by it; in fact this disease proves that a specific region in our brain is delegated to recognize known faces and this brain region plays an active and specific part in social relations. In other words, during the evolution of the human kind a brain region specialized in storing information on the faces of the people with whom the individual has significant relations of love and affection. Beyond its biological foundation, mutual trustfulness is likely to improve the quality of life of the members of a society. Trust is also likely to reduce the costs and risks of both economic and non-economic activities [12]. Better health outcomes were found in countries with higher values of social capital [12,35]. However unemployment leads, per se, to lower subjective wellbeing more than the usual measures of its economic cost [26]. It is likely, and in some way obvious, that people more prone to trust the others will also be more often involved in social relationships than the people who are distrustful and withdraw from their peers. However, to display reciprocity one should be able to encounter other people and to afford an exchange of resources. Unemployment attacks this essential quality of human interactions. Job loss implies the breaking of the social relationships embodied in the workplace. Because of financial difficulties, unemployed people are also forced to curtail any unnecessary recreational expense, thus further decreasing their opportunity to exert relational exchanges. Moreover, financial difficulties and the curtailment of social relationships make unemployed people less able to somehow reciprocate the resources they get from the others, and even less able to offer anything valuable in the first place. Where unemployment rates rise concurrently to a decrease in the social capital, suicide rates grow rapidly. In the former Soviet Union and, later on, in Russia, suicide rates moved from an average of 3 per 100,000 in the first decades of the 20th century to about 40 per 100,000 in 1999, after the collapse of Soviet economy. The risk of depleted sociality ensuing from unemployment is thus a severe threat to survival, well and beyond its financial impact. Unemployment and mental health The pathways to unemployment are manifold and complex. However people with a mental disorder, many of the latter entailing a higher risk of suicide, are significantly more likely to lose their job, or even to be unable to have access to paid employment. Acknowledgment of mental disorders is mandatory for proper treatment: whenever a mental disorder is recognized as a relevant contributing factor in the decay of an individual’s social efficiency, aggressive treatment of the disorder should be made accessible at a cost affordable by people devoid of financial support. The improvement of mental health is also likely to improve a person’s ability to reenter the job market. Regaining work competence would make the subject more able to contribute to social networks, thus improving the quality of life of their immediately surrounding people. Increased productivity will also reduce the costs of survival for their families, and will limit the costs of assistance, welfare and social security for the society as a whole. 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To cite this article: Preti A., Miotto P., Suicide, unemployment and social capital , [in:] Niebrój L., Kosińska M., Unemployment and Health Care, Katowice: Wyd. SAM 2004, p. 49-56