Suicide in Greece 1992–2012: A time-series analysis

Abstract

Background and aims:

Since 2008, Greece has entered a long period of economic crisis with adverse effects on various aspects of daily life. In this frame, it is quite important to examine the suicide trends in Greece.

Method:

Our analysis covered the period 1992–2012. 2012 was the last year for which official suicide data were available. The inclusion of data for pre-crisis period enabled us to assess trends in suicide preceding the economic crisis, starting in 2008. Trends in sex- and age-adjusted standardized suicide rates (SSR) were analyzed using joinpoint regression.

Results:

Total SSR presented statistically significant annual decrease of 0.89% (95% confidence interval (CI): −1.7, −0.1) during the period 1992–2008. After 2009, the trend in total SSR increased statistically significant annual increase (12.48%; 95% CI: 0.3%, 26.1%). SSR in males presented an initial period of modest annual decrease (−0.84%; 95% CI: −1.6%, −0.1%), during the period 1992–2008. After 2009, an annual increase by 9.25% (95% CI: 2.7%, 16.3%) was revealed. No change in female SSR trend was observed during the studied period.

Conclusion:

According to the results of this study, there is clear evidence of an increase in the overall SSR and male SSR in Greece during the period of the current financial crisis.

Keywords

Suicide economic crisis time series Greece

Introduction

Suicide constitutes one of the major public health problems worldwide. Every year almost 1 million people die from suicide, which means a ‘global’ mortality rate of 16 per 100,000, or one death every 40 seconds (World Health Organization (WHO), 2007). It has been suggested that suicide is a complex phenomenon and the result of multiple factors including mental disorders and recent loss (Bertolote & Fleischmann, 2002; Cavanagh, Carson, Sharpe, & Lawrie, 2003; Isometsa, 2001).

The association between financial problems, financial insecurity, unemployment and poor mental health is well established in westernized societies (Catalano, 1991; McKee, Karanikolos, Belcher, & Stuckler, 2012; Stuckler & Basu, 2009; Stuckler, Basu, Suhrcke, Coutts, & McKee, 2009; Stuckler, Basu, Suhrcke, & McKee, 2009; Uutela, 2010). Research evidence from many countries indicates that economic recession is associated with increases in suicide, particularly in males of working age (Haw, Hawton, Gunnell, & Platt, 2015).

Since 2008, Greece has entered a long period of economic crisis with adverse effects on various aspects of daily life. Although earlier studies have found an increase in suicides (Fountoulakis, Koupidis, Grammatikopoulos, & Theodorakis, 2013; Kontaxakis et al., 2013) and suicide attempts (Economou, Madianos, Peppou, Theleritis, et al., 2013) during this crisis, these findings have been criticized on the grounds that the numbers were too low to reach a definite conclusion (Rachiotis, Stuckler, McKee, & Hadjichristodoulou, 2015). In addition, the increase in suicide observed has been considered to be a sign of random temporal fluctuation in suicide rates and does not constitute a change in suicide trend during the crisis (Fountoulakis, Grammatikopoulos, Koupidis, Siamouli, & Theodorakis, 2012). In this frame, it is quite important to examine the suicide trends in Greece over a long period of time in order to identify significant changes and whether any change coincides with the onset of the recent economic crisis.

Materials and methods

Population data and crude data on suicides were obtained from the Hellenic Statistical Authority (ELSTAT, 2013c). Our analysis covered the period between 1992 and 2012 (2012 was the last year for which official suicide data were available). The inclusion of data for pre-crisis period enabled us to assess trends in suicide preceding the economic crisis that started in 2008 in order to distinguish the effect of crisis from pre-existing underlying trends. We assessed the age-standardized suicide rates (SSR), using population data based on the 1991, 2001 and 2011 censuses. The de facto population of Greece was 10,259,900 in 1991, 10,964,020 in 2001 and 10,939,727 according to the 2011 census (ELSTAT, 2013a). Age-adjustment was performed by the direct standardization method, using the European Standard Population (ESP) in order to facilitate comparisons controlling for differences in the population distribution occurring during time (WHO, 2001). Trends in sex-specific SSR were analyzed using joinpoint regression, in which trend data are characterized by a number of contiguous linear segments and join points (JPs; points at which trends change). These models were used to estimate the annual percent change (APC) in rates and the number and location of JPs, based on linear regression with the log suicide rates as the dependent variable and the year as the independent variable (Chang, Gunnell, Sterne, Lu, & Cheng, 2009; Kim, Fay, Feuer, & Midthune, 2000). Analyses were conducted using Joinpoint Regression software (version 4.1, National Cancer Institute, Bethesda, US National Institute of Health, 25 April 2014).

Results

During the study period (1992–2012), 8,025 suicides occurred, 6,536 (81.4%) by males and 1,489 (18.6%) by females. The mean SSR was 3.13/100,000 inhabitants, the mean male SSR 5.25/100,000 and the mean female SSR 1.14/100,000. The estimated general population of Greece in the middle of each year, the absolute number of suicides – male, female and total – and the sex-specific SSR are shown in Table 1. The lowest male suicide rate was observed in 2002 (4.24/100,000) and the highest in 2012 (6.67/100,000). Suicide rates in females were lower, with an average male to female suicide ratio equal to 4.6 for the whole period of the study. The lowest female suicide rate was observed in 2010 (0.63/100,000) and the highest in 1993 (1.78/100,000).

Table 1.

Estimated general population of Greece in the middle of each year (1992–2012), absolute total, male and female number of suicides and age-standardized suicide rates (SSR).

Year	Population	Suicides (absolute number)			Age-standardized suicide rates
Year	Population	Total	Male	Female	Total	Male	Female
1992	10,369,828	351	279	72	3.13	5.19	1.23
1993	10,465,534	412	308	104	3.66	5.64	1.78
1994	10,553,032	355	281	74	3.10	5.11	1.20
1995	10,634,391	370	306	64	3.18	5.46	1.06
1996	10,709,150	356	294	62	3.04	5.19	0.98
1997	10,776,531	374	319	55	3.19	5.57	0.90
1998	10,834,910	403	315	88	3.39	5.43	1.49
1999	10,882,607	381	296	85	3.19	5.13	1.35
2000	10,917,457	382	298	84	3.16	5.07	1.35
2001	10,951,781	334	286	48	2.76	4.83	0.77
2002	10,983,721	323	257	66	2.57	4.24	1.00
2003	11,018,301	375	306	69	3.10	5.18	1.13
2004	11,055,697	353	285	68	2.80	4.67	1.05
2005	11,092,923	400	321	79	3.11	5.14	1.25
2006	11,127,921	402	330	72	3.15	5.24	1.18
2007	11,163,026	328	268	60	2.62	4.41	0.91
2008	11,186,479	373	308	65	2.89	4.88	1.00
2009	11,187,103	391	333	58	3.07	5.39	0.87
2010	11,153,470	377	336	41	2.92	5.36	0.63
2011	11,123,261	477	393	84	3.80	6.42	1.32
2012	11,092,783	508	417	91	3.96	6.67	1.42

Figure 1 displays the total, male and female SSR during the period 1992–2012, with line segments from joinpoint regression models.

Figure 1.

The total, male and female SSR during the period 1992–2012, with line segments from joinpoint regression models. APC coefficients are the annual percent changes in suicide rates in the years between the specified join points. Negative coefficients indicate downward trends; positive coefficients indicate upward trends. Join points (JPs) are years when changes in trends in suicide rates occur.

Table 2 displays the APC in total, male and female SSR and JPs for trends in sex-specific SSR in Greece during the years 1992–2012. In total SSR, a statistically significant annual decrease of 0.89% (95% confidence interval (CI): −1.7%, −0.1%) was found during the period 1992–2009. After 2009, the trend in SSR increased significantly (annual increase 12.48%; 95% CI: 0.3%, 26.1%). In male SSR, an initial period of modest annual decrease (−0.84%; 95% CI: −1.6%, −0.1%) during the period 1992–2008 was observed. Joinpoint regression analysis revealed a change in male SSR trend during 2008, after which the average annual increase was 9.25% (95% CI: 2.7%, 16.3%). No change in female SSR trend was observed during the whole study period.

Table 2.

The annual percent change (APC) in suicide rates and join points (JPs) for trends in age-standardized suicide rates (SSR) in Greece, 1992–2012.

	JP	Segments
Total	2009	Segment 1 (1992–2009)		Segment 2 (2009–2012)
		APC^a	95% CI	APC^a	95% CI
		−0.89%	−1.7%, −0.1%	12.48%	0.3%, 26.1%
Males	2008	Segment 1 (1992–2008)		Segment 2 (2008–2012)
		APC^a	95% CI	APC^a	95% CI
		−0.84%	−1.6%, −0.1%	9.25%	2.7%, 16.3%
Females	–	Segment 1 (1992–2012)
		APC	95% CI
		−1.15%	−2.9%, 0.6%

APC coefficients are the annual percent changes in suicide rates in the years between the specified join points. Negative coefficients indicate downward trends; positive coefficients indicate upward trends. Join points (JPs) are years when changes in trends in suicide rates occur.

APC statistically significant at p < .05.

Discussion

According to the results of our study, there is clear evidence of a statistically significant increase in the overall and male SSR in Greece during the period of the current financial crisis (2009–2012). The results revealed an increase in suicides for the total population and male population by 28.99% and 23.75%, respectively, in age-SSR. Moreover, joinpoint regression analysis revealed significant increase in total and male SSR trend at the beginning of the crisis.

A previous study by the authors (Kontaxakis et al., 2013), comparing suicide rates during a time period before the crisis (2001–2007) and during the crisis (2008–2011) in 5-year age groups of both sexes, revealed an increase in total SSR during the crisis by 27.2% and in male SSR by 26.9% with a differential effect across age groups. More precisely, a statistically significant increase in suicide rate was revealed in men aged 30–34, 45–49, 50–54 and 60–64 years, while there were no statistically significant differences in suicide rates in all female age groups. Another recent study looking for determinants of changes in suicide rates during this Greek economic crisis found a significant association between male unemployment rates and suicides among working age men 15–64 years but not between female unemployment and suicides among women (Rachiotis et al., 2015). These findings are in line with the findings of previous studies indicating a differential effect of recession on different age groups according to employment status (Gunnell et al., 1999; Gunnell, Middleton, Whitley, Dorling, & Frankel, 2003). Significant increase in male but not female SSR during periods of crisis has been observed in other parts of the world as well (Yip, 2008); for example, in the Baltic region in the beginning of the 1990s reached the incredible level of 5.5-6 to 1 (Varnik, Sisask, & Varnik, 2010). Evidence also shows that employment status plays a more important role in suicide for males than for females (Qin, Agerbo, Westergard-Nielsen, Eriksson, & Mortensen, 2000). It has been proposed that the stronger association between unemployment and male suicide may be explained by gender differences in the impact of job loss, especially in terms of status, routine and social support (Payne, Swami, & Stanistreet, 2008). Women retain another status through their domestic and caring responsibilities, whereas men may experience significant gender role confusion as a result of unemployment.

It is worth to note that previous studies on changes in suicide rates in Greece either used crude suicide rates (Kontaxakis et al., 2013; Rachiotis et al., 2015) or age-adjustment was performed based on the population of Greek censuses and not on ESP according to the WHO standards. Therefore, changes found in these studies were not controlled for differences in the population distribution occurring during time. Only one previous study used ESP for age-standardization (Fountoulakis et al., 2012), examining however trends during a shorter overall period (2000–2010) and including only 2 years of economic recession. Another strength of our study is the use of joinpoint regression in which no assumption on the time of significant change (e.g. the onset of the crisis) is made. For example, numerical fluctuation in male SSR can be observed before 2008 but without a significant change in trend until then.

Suicide rates in Greece are among the lowest in Europe. However, Greece has entered since 2008 in a period of continuous recession (the sixth year in a row). The national debt rose from 107.3% in 2007 to 170.3% in 2011, the per capita gross domestic product (GDP) has decreased significantly (from 20,758 Euros in 2008 to 17,161 in 2012, i.e., 17.3% decrease) and unemployment has risen from 7.7% in 2008 to 24.4% in 2012 and it is still rising (ELSTAT, 2013b, 2013c). The percentage of the population at risk of poverty or social exclusion was 27.6% in 2009 and it climbed to 31% in 2011. The percentage of the population at risk of material deprivation was 21.8% in 2008 and slowly climbed to 28.4% in 2011 (ELSTAT, 2013b, 2013c). Even though suicide mortality is underestimated if figures are based on death certificates alone and our study included only the initial phase of recession (2008–2012), our results indicate an association between financial crisis and suicide, especially in men. However, the design of the study does not allow for causal inferences to be made since we used data from quite crude measures which only provide correlations on a highly aggregated level.

On the other hand, previous studies using different methodologies found a significant association between financial crisis and many aspects of suicidality in Greece. According to these results during the current crisis, there was an increase in suicidal ideation (Economou, Madianos, Peppou, Patelakis, & Stefanis, 2013; Economou, Madianos, Peppou, Theleritis, et al., 2013; Economou, Madianos, Peppou, Theleritis, & Stefanis, 2012), suicide attempts (Economou, Madianos, Peppou, Theleritis, et al., 2013; Stavrianakos et al., 2014) and suicide rate (Arie, 2013; Fountoulakis et al., 2013; Kentikelenis, Karanikolos, Reeves, McKee, & Stuckler, 2014; Kentikelenis & Papanicolas, 2012; Kondilis, Giannakopoulos, et al., 2013; Kondilis, Ierodiakonou, Gavana, Giannakopoulos, & Benos, 2013; Kontaxakis & Havaki-Kontaxaki, 2012; Kontaxakis et al., 2013). Preliminary media data for the year 2013 indicate that suicide rates continue to rise although the magnitude of increase is still unknown.

In conclusion, our findings indicate that Greek economic crisis is associated with increase in suicide, particularly in men, in agreement with the findings with many other studies from countries around the world. Previous research identified unemployment, financial loss, bankruptcy and home repossession as possible factors that may lead directly or indirectly to mental health problems, including suicidal behavior (Haw et al., 2015). Therefore, it has been suggested that mental health impact of the economic crisis can be offset by various policy measures, such as social welfare supports, active labor market programs, family support programs, accessible and responsive primary care services, and modernization of mental health care provision (Wahlbeck & McDaid, 2012). Other measures likely to help in suicide prevention include targeted interventions for unemployed people, membership of social organizations and responsible media reporting (Haw et al., 2015). Policy measures that strengthen the social safety net and targeted interventions are needed to prevent or to mitigate the impact of financial crisis on mental health of the Greek population during the next years.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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