The impact of previous recessions on mental health: implications for the current economic crisis Eva Elliott, Emily Harrop, Michael Shepherd, Heather Rothwell, Gareth Williams

Research objectives To identify and explain how the recession may impact directly on health and through its determinants across the social gradient. To identify additional population groups who may be particularly vulnerable or resilient to the effects of the recession To characterise the effects of previous government and public agency measures taken to respond to financial crises on health To identify and characterise the potential material, cultural, and psycho-social resources that reside within communities themselves that produce related vulnerability and resilience To map available evidence on impact to existing policy divisions and service areas in the Welsh Assembly Government, local government, regeneration, and health and social care services.

Methods Literature review: what is known about the effects of recession as well as the effectiveness of measures to respond to them Expert interviews: officials in two localities working in sectors associated with main determinants Policy dialogue, with national and local stakeholders, to discuss emerging findings and issues to provide the review with a context to refine conclusions and recommendations (February 2010)

Recession today Different in character to earlier recessions in UK – financial sector relatively stable previously Significant national debt (predicted impact on public sector) Interaction with pension insecurity, unsustainable housing loans/debt, interaction with welfare ‘reforms’ (conditionality) Impact greatest on younger people, rise in employment in post –state retirement age, impact greatest in men but set to change with public sector cuts.

ANTICIPATION OF RECESSION

Source: Audit Commission (2009) When it comes to the Crunch…Responding to the economic downturn: the role and potential of partnerships

Recession, unemployment and health Some positive health impacts associated with economic recession Links between economic recession and health behaviours (smoking, alcohol and physical activity) are contested but stronger associations with long term unemployment However unemployment a key factor affecting health in a recession Unemployment associated with increases in increased mortality (all causes, cardiovascular disease, suicide) and mental health However the impact of recession depends on how governments deal with them

Theories for understanding better health through hard times Coping “cognitive and behavioural efforts used to contend with events appraised as stressful” Resilience “the successful” adaptation to life tasks in the face of social disadvantage or highly adverse conditions’ Salutogenesis Factors associated with health (ease) as opposed to disease processes

Individual Most of the literature focuses on individual coping styles and strategies (problem based and symptom based) in relation to perceived stressors (job insecurity and job demand), how job loss is appraised and personality type Suggestion that HR departments have a role in supporting people coping with job insecurity and possible job loss Strategies aimed at finding jobs not necessarily best for health (measures of resilience or hardiness not protective over time) – dependent on local labour markets Involvement in non-work activities may provide latent functions of work in areas of job scarcity Most research stresses the importance of social support in minimising distress Having a supportive partner is an important protective factor in coping with job loss (however job loss also erodes family and marital relationships)

Community/Neighbourhood High levels of small area ‘social cohesion’ may protect mental health in areas of deprivation and through hard times However the social capital produced in these environments is threaten by chronic labour market insecurity and inequality Investment in local economies crucial to prevent widening spatial inequality Collective efforts to address unemployment has psychological benefits for redundant workers as well as addressing the community impacts of unemployment

National Policy Suggestion that governments with strong social/financial support for low income/unemployed protective of health Levels of psychological distress may be lower in countries with high levels of government financial support for the unemployed Cross sectional data from the European Social Survey found the magnitude of unemployment/ health relationships varied by type of welfare state regime

INTERVENTIONS Few interventions directed at supporting unemployed have been evaluated on health impact Youth Opportunity Schemes found to have a negative impact on mental health. Three main approaches in those that have been evaluated – Strengthening individuals – Supportive environments

JOBS programme (USA) Developed in late 80s in Michigan – (replicated in Finland, Israel and China) – dual aims of promoting reemployment and enhancing coping capacities for the unemployed and their families – Provided skills on how to seek reemployment how to deal with barriers and setbacks – RCT – higher levels of self confidence and self efficacy and lower levels of depression than control group – Particularly effective with persons at high risk of depression – Differences in outcome when used during economic stability and in recession – Similar programme in Sweden (but poor evaluation study)

A mentorship program for men (Australia) Aimed at developing: – social networks of people who were unemployed – the capacity of local community organisations to develop social networks that would reduce isolation, support skill development, and increase access to information and resources Participants were men over 40 (n = 126) still looking for work Groups of 5-10 allocated 1-2 mentors Group sessions lasted for 2 hours over an 8 week period and served the dual role of providing practical skills as well as a social support network Results demonstrated improvements in mental health (using measures of depression and anxiety) as well as improved measuring in efficacy, optimism, self-esteem and social support.

“Use for Everyone” (Sweden) Aimed to stimulate grass roots initiatives to create supportive environments for the unemployed, people on long-term sick leave or those otherwise involuntarily excluded from the active labour force Outcomes - psychosocial health, defined as “a measure of how much influence people have over their own lives” Project leaders were recruited and trained from the target groups. These groups were to become self governing social environments Over a 3 year period 850 people participated in the project. Longitudinal data indicate that self-rated health and quality of life improved during participation, and were maintained at 6 month follow up Criticism that improvements in mental health may have been associated with adaptation to unemployment role rather than empowerment

Are our communities prepared? “when you had industry in the local area you had a community and I think even on the news recently you’ve probably seen articles about why don’t we know our neighbours anymore, well most of us used to work together and a lot of the adults used to mentor young people when they first started work… you know, where somebody’s working alongside them, not just monitoring them and watching them every half hour and peeping in to see what they’re up to but actually doing the job with them and showing them the ropes and that sort of thing.’ (health & social care) I don’t think that I’ve really seen the community spirit to the fore, at the moment in this part of the recession. There’s not the working together to look for ways out of it and that’s probably because there’s been so much over the last 30 years, with the rundown of the steel and iron works, that people can’t see how there can be a major change in opportunities locally that they can influence. The, I kind of think that is reflected in the sort of turn outs for elections and participation in community events, carnivals, you know generally folk is a good indicator of community participation and despite trying to, a number of organisations trying to revive the carnival, it just isn’t happening.’ (community development)

What is to be done? Recognise that efforts to protect health and address inequality need to be developed now HR departments in public sector organisations should be developing support strategies to address job uncertainty within their own organisations Interventions are needed to prevent debt and support those in debt Identify ways of pooling resources across sectors to strengthen health and welfare provision Ensure that new approaches to delivery of essential services to vulnerable people retain quality and are sustained in hard financial times. Health impact assessments need to be undertaken on public services expenditure to ensure vulnerable groups are protected and supported Need to address barriers that prevent young people from entering training and further education Support existing community level initiatives that strengthen social cohesion and promote social support Evaluate job support interventions in terms of their impact on health and inequality