Unemployment, Behavioral Health, And Suicide
KEY POINTS:
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One of the most immediate consequences of both the COVID-19 pandemic and the US response to it was a surge in American job loss. In April 2020 US unemployment skyrocketed from less than 5 percent to almost 15 percent. More than a year later, in December 2021, the unemployment rate remained higher than prepandemic levels, although after April 2020 it dropped nearly every month. This sudden increase in unemployment caused speculation about its negative impacts on Americans’ mental health. Researchers and advocates worried about increases in suicide.
This policy brief focuses on unemployment and suicide and describes promising approaches to mitigating the impact of job loss on suicide risk. Although we tie our brief to COVID-19, changes in unemployment are a continual issue: in September 2021 Moody’s warned that a possible US government default would increase national unemployment to 9 percent, equal to the loss of six million jobs.
In many ways suicide represents the “tip of the iceberg” as one of many measures of population distress. Many of the unemployment-related factors that may increase suicide risk also affect other mental and behavioral health outcomes, such as depression or hazardous drinking. However, because more than half of those with mental and behavioral health issues do not access treatment and because high-frequency surveys that measure distress in the American population are a relatively recent phenomenon, the suicide rate—a finite data point that is routinely collected—can help us understand the relationship between unemployment rates or job loss and distress, with data readily available and a corresponding depth of research. When relevant, we draw on pertinent literature describing the effects of job loss on other mental and behavioral health indicators.
Suicide In The United States
A recent Health Affairs Health Policy Brief provides an overview of suicide in the United States. In 2019, 47,511 Americans intentionally ended their lives, making suicide the tenth leading cause of death. This is likely an underestimate—in 2019, 75,795 Americans died of poisonings, the majority of which were drug poisonings categorized as unintentional, although some were likely suicide overdoses that were misclassified.
Suicide is a growing national concern despite the fact that the national suicide rate decreased between 2018 and 2019 and again in 2020. This decrease comes after nearly twenty years of the national suicide rate increasing annually, and it was not observed in some minority racial and ethnic groups. In addition, although suicide rates decreased between 2018 and 2020, the drug overdose death rate increased.
There is current and historic variation in suicide rates among adults both by race and ethnicity and by sex, with the highest rates and largest increase in rates during the past two decades seen among American Indian or Alaska Native adults. Recent national efforts have called for research to explain drivers of these trends and steps needed to mitigate them.
Recent data present a nuanced picture of suicide rates during the COVID-19 pandemic (exhibit 1). Our analysis of data from the CDC’s Wide-ranging Online Data for Epidemiologic Research (WONDER) indicates that in 2020 there were 45,979 suicide deaths (crude rate = 14.0 per 100,000 population) relative to a crude rate of 14.5 per 100,000 in 2019 (exhibit 1). Although this represents a total decrease, the rate for Black men increased from 12.4 to 13.2 per 100,000 between 2019 and 2020. For American Indian and Alaskan Native men, the rate increased from 33.4 to 37.8 per 100,000, and for Hispanic men it went from 11.3 to 12.0 per 100,000. For women, rates across all racial and ethnic groups decreased or remained constant. These patterns correspond to similar national trends observed between 2018 and 2019.
EXHIBIT 1 Suicides in the United States and rates by sex and race and ethnicity, 2018–20
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|
2018 |
2019 |
2020 |
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|
No. |
Crude rate |
No. |
Crude rate |
No. |
Crude rate |
|
|
Total |
48,344 |
14.8 |
47,511 |
14.5 |
45,979 |
14.0 |
|
Men |
37,761 |
23.5 |
37,256 |
23.0 |
36,551 |
22.5 |
|
Women |
10,583 |
6.4 |
10,255 |
6.2 |
9,428 |
5.6 |
|
American Indian or Alaska Native, non-Hispanic |
615 |
22.4 |
610 |
22.1 |
663 |
24.0 |
|
White, Non-Hispanic |
38,643 |
19.2 |
37,672 |
18.8 |
35,716 |
17.8 |
|
Black, non-Hispanic |
3,124 |
7.3 |
3,218 |
7.4 |
3,415 |
7.8 |
|
Asian or Pacific-Islander, non-Hispanic |
1,502 |
7.3 |
1,548 |
7.5 |
1,502 |
7.1 |
|
Hispanic |
4,313 |
7.2 |
4,331 |
7.2 |
4,571 |
7.5 |
Source: Authors’ analysis of data from Wide-ranging Online Data for Epidemiologic Research (WONDER).
Notes: Crude rate is per 100,000 population.
State-level estimates have been published for select periods in 2020 for Massachusetts, Maryland, and Connecticut, suggesting no changes in suicide rates among the total population but disproportionate increases during the pandemic among racial and ethnic minority populations in Maryland and Connecticut. Although data from just three states should not be interpreted as being representative of national trends, they do point to hypotheses that should be prioritized for examination by other states.
Unemployment And The COVID-19 Recession
The COVID-19 recession arrived at a time during which there were already alarming trends regarding the US labor market and suicide. Between 2000 and 2019 labor force participation of men between ages twenty-five and fifty-four dropped from 92 to 89 percent and “deaths of despair,” including suicide, overdoses, and liver cirrhosis, increased among similarly middle-aged White men, particularly those with lower educational attainment.
April 2020 saw the highest monthly unemployment rate (14.8 percent) in the US since data collection began in 1948; for comparison, in the recessions in the early 1980s and 2009, peak unemployment rates hovered at around 10 percent. No state was immune, but job loss was not experienced equally across all workers. Those most affected were workers employed in industries that provide in-person services and those who worked in smaller enterprises.
Job loss also occurred differentially by sociodemographic factors:
- Gender: Unemployment rates increased more for women than men (especially among workers younger than twenty-five).
- Age: Unemployment rates increased more for workers younger than twenty-five than for older workers.
- Race: Unemployment rates were higher for Black compared with for White and Asian American workers; they also took longer to improve for Black and Asian American workers than for White workers.
- Ethnicity: Higher rates of unemployment were observed among Hispanic than non-Hispanic workers.
- Education: Higher rates of unemployment were observed among those with less than a high school or college degree compared with those with some college or an associate’s or bachelor’s degree.
Just as it skyrocketed in April 2020, the unemployment rate dropped by 8 percentage points to 6.7 percent by December 2020 as laid off and temporarily furloughed workers returned to work. However, this rate was still higher than the prepandemic level of less than 5 percent. In November 2020 the Congressional Budget Office and the Federal Reserve projected elevated unemployment rates higher than 6 percent until approximately 2024—however, by May 2021 the rate was already at 5.8 percent and has continued to drop. This does not necessarily mean that those who lost their jobs have been reemployed. Unemployment estimates only include those people not working and looking for jobs; it does not capture those who have left the workforce entirely, including many women workers who left their jobs and have not returned because of competing child care responsibilities.
Unemployment And Suicide
The research relating unemployment or job loss to suicide is complex. Research has typically exploited ecological designs that examined how changes in unemployment across states or countries are associated with corresponding changes in suicide rates. The most recent US-based studies have generally focused on the Great Recession from 2007 to 2009. This research finds that a 1-percentage-point increase in unemployment is associated with a 1 percent to 1.6 percent average increase in suicide rates. However, other research on the Great Recession found no evidence of a relationship between unemployment and suicide in the US when accounting for seasonality and nonlinear trends in suicide rates.
There are important considerations when extrapolating this ecological research to future recessions, including the COVID-19 recession. First, the change in unemployment associated with COVID-19 was unique in its magnitude and sudden recovery. Second, women and racial and ethnic minorities were disproportionately affected in the COVID-19 recession, and these groups have historically had lower baseline rates of suicide (although, as noted, suicide rates for many racial and ethnic minorities have recently been increasing). Third, different workers lost jobs during the Great Recession than during the pandemic: for example, during the Great Recession service occupation employment actually grew, but during COVID-19 unemployment has been concentrated among workers in industries that provide in-person services.
Three factors are especially salient in moderating the relationship between unemployment and suicide:
- Regionality: There is variation in job loss across communities and states during recessions. Similarly, suicide rates vary across states and communities; for example, suicide rates are elevated in rural American communities. Therefore, unemployment may have differential effects on suicide rates in different regions. There is evidence that during the Great Recession the effect of job loss on suicide rates was stronger in states with greater female labor force participation.
- Availability and amount of unemployment benefits: A US-based study found that the generosity of state unemployment benefits moderated the effect of unemployment on suicide among those ages 20–64. One cross-national study examined variation in employment supports across twenty Organization for Economic Cooperation and Development (OECD) countries and found that more generous national unemployment protections buffered the relationship between unemployment and suicide among those ages 24– However, in a study of Western European countries from 2000 to 2010, the association between unemployment and suicide was strongest in France, which had the highest OECD employment protection index of the countries studied.
- Duration and magnitude of changes in unemployment: One study suggests that suicide may follow job loss more immediately when there is a sudden, dramatic change (for example, mass layoffs) as opposed to smaller, month-to-month employment fluctuations. For those who do lose jobs because of these normal fluctuations, the duration of unemployment rather than job loss itself is more strongly associated with suicide risk.
Job Loss And Other Mental And Behavioral Health Outcomes
Investigations into the relationship between job loss and other mental and behavioral health outcomes are generally based on a limited number of cohort studies that examined whether job loss increases risk for incident symptoms. Methodologically, establishing a causal relationship is difficult because mental health symptoms can also lead to loss of employment. There is evidence that those with serious psychological distress before the COVID-19 pandemic were at increased risk for job disruption during the pandemic.
A 2009 meta-analysis reviewed nineteen longitudinal studies of people who lost jobs, finding a pooled effect of job loss on distress. The analysis also provided evidence of improvements in distress on gaining employment. Evidence from the US supports the relationship between job loss and depressive symptoms among older workers and adult workers, although the relationship may be moderated by education (higher levels of education confer a protective effect) and, differentially, occupational prestige (higher levels of prestige confer increased risk for depression). There is also evidence that Americans who lost a job in the past year increased their alcohol consumption.
Implications And Interventions
There are at least three key takeaways from existing research that may inform future policy action. First, the effect of unemployment on suicide rates during COVID-19 will play out among subpopulations differently, particularly among Americans in racial and ethnic minority groups and women, both of whom were disproportionately affected during COVID-19. Second, reemployment may be as much an issue as job loss: those who are out of work longer may be at elevated suicide risk depending on the benefits and social supports available to them. Third, there are opportunities to mitigate the effects of job loss on suicide risk, discussed below. These interventions may take the form of both public policies that bolster income and protect health insurance for all workers and direct interventions among those at risk for or who have experienced job loss.
Public Policies
More generous state-level unemployment programs may buffer the effect of job loss on suicide risk. Other policies not directly related to unemployment but that support those who are struggling financially may also protect against suicide risk. In longitudinal analyses, states with a higher percentage of their population participating in the Supplemental Nutrition Assistance Program had reduced state suicide rates. Although some research found evidence that generosity of the earned income tax credit is significantly associated with reductions in state suicide rates for adults ages twenty-five and older, other research has failed to find such evidence after adjusting for socioeconomic factors, population size, and population characteristics.
The COVID-19 recession disproportionately affected women who left the workforce for a range of reasons including increased child care demands during school closures. Child care support and child tax credits may help employees maintain their jobs and support their children. There is evidence that child tax credits can reduce childhood medical injuries and behavior problems. Research should investigate the association between these benefits and state-level suicide rates, particularly among women, as well as the impact of temporary changes to the Child Tax Credit in 2021 that made it expandable and advanceable (these changes expired in 2022 and have not been renewed as of this writing). Workplace supports such as flexible hours or opportunities to disclose mental health conditions without fear can similarly help retain those with mental health conditions in the workforce.
Finally, evidence-based interventions can reduce suicide risk, including cognitive behavioral therapy (a psychotherapeutic approach that helps people change maladaptive patterns of thinking or behaving) and dialectical behavior therapy (which emphasizes mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills). Other evidence-based treatments exist for depression and anxiety, and pharmacologic therapies and psychotherapies are available for alcohol and other substance use disorders. Health insurance helps ensure that those with mental health needs can access these treatments. Providing unemployed people with access to affordable health insurance that covers high-quality, evidence-based mental health care, including telehealth, is a critical suicide prevention strategy relevant to those who had mental health needs before the pandemic as well as those whose symptoms developed during the pandemic. Under the American Rescue Plan Act of 2021, people who received or who were approved to receive unemployment compensation in 2021 were eligible for maximal health insurance subsidies under the Affordable Care Act, although it is unclear yet how many people took advantage of this benefit.
Finally, policies that allow for reimbursement of mental health services delivered by “lay providers” (for example, via task sharing) can help offset demand for the highly limited supply of mental health providers while also improving access to care.
Direct Interventions
In addition to treatments such as dialectical behavior therapy and cognitive behavioral therapy that address factors directly contributing to suicide and mental and behavioral health conditions, new approaches have been tailored specifically for unemployed people experiencing mental health issues. In New York City, Connections to Care is an initiative integrating mental health services into the regular programming of organizations that offer employment and training support. An evaluation showed that those who received Connections to Care services had reduced residential mental health treatment use and increased work hours and pay at the one-year follow-up assessment relative to people who did not receive Connections to Care assistance.
A separate study examined mental health programming for primarily Black youth receiving services from a single employment training program that resulted in significant reductions in depressive symptoms at twelve months among males with high baseline depressive symptoms. Considering pressing mental health worker shortages, both this program and the Connections to Care initiative leveraged and enhanced the skills of existing staff at community-based organizations rather than relying on overstretched mental health providers.
Other interventions are in development. There is a current study, supported by the National Institute of Mental Health (NIMH) that is testing work-related group cognitive behavioral therapy for unemployed persons with social anxiety. Findings from the initial pilot trial demonstrated improvements in mental health outcomes, job search activity, and self-efficacy. NIMH and the National Institute on Drug Abuse have published a notice of special interest for research on strategies to enhance mental health interventions and services within employment and job training settings.
Conclusion
COVID-19 has led to historic disruptions in the nation’s workforce, which may affect suicide rates. As more data become available, the relative impact on populations historically experiencing health disparities will be better understood. Preliminary evidence may suggest disproportionate increases in suicide rates during the pandemic among some racial and ethnic minority populations.
It is also important to consider both the pandemic and the corresponding mitigation strategies (for example, ”stay-at-home” orders, at-home or virtual schooling) as happening in stages. Suicide risk is complex, driven by both static and dynamic risk factors. Research that captures fluctuations in such factors over time can help illuminate who is at risk, in what window of time, and in relation to the presence or absence of which available supports. This is likely to inform strategies to improve suicide prevention and mental health promotion among the un- and underemployed. The National Institutes of Health is supporting studies that seek to address these questions through social, behavioral, and economic research on COVID-19. There is also accumulating evidence that enhancing access to evidence-based mental health care for unemployed people through nontraditional settings and care pathways (for example, workforce development programs) could help to prevent suicide and other mental and behavioral health problems in vulnerable communities.
Acknowledgment
All briefs go through peer review before publication. The opinions expressed in this article are the authors’ own and do not necessarily reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.