Cause and effect in studies on unemployment, mental health and suicide : a meta-analytic and conceptual review

Background. There are ongoing questions about whether unemployment has causal effects on suicide as this relationship may be confounded by past experiences of mental illness. The present review quantified the effects of adjustment for mental health on the relationship between unemployment and suicide. Findings were used to develop and interpret likely causal models of unemployment, mental health and suicide. Method. A random-effects meta-analysis was conducted on five population-based cohort studies where temporal relationships could be clearly ascertained. Results. Results of the meta-analysis showed that unemployment was associated with a significantly higher relative risk (RR) of suicide before adjustment for prior mental health [RR 1.58, 95% confidence interval (CI) 1.33-1.83]. After controlling for mental health, the RR of suicide following unemployment was reduced by approximately 37% (RR 1.15, 95% CI 1.00-1.30). Greater exposure to unemployment was associated with higher RR of suicide, and the pooled RR was higher for males than for females. Conclusions. Plausible interpretations of likely pathways between unemployment and suicide are complex and difficult to validate given the poor delineation of associations over time and analytic rationale for confounder adjustment evident in the revised literature. Future research would be strengthened by explicit articulation of temporal relationships and causal assumptions. This would be complemented by longitudinal study designs suitable to assess potential confounders, mediators and effect modifiers influencing the relationship between unemployment and suicide.