The economic crisis and its impact on mental health
G. BOURAS*, L. LYKOURAS**
*PhD, Psychologist, 2nd Psychiatry Dept. E.K.P.A.
**MD, PhD, FICPM, Psychiatrist-Professor, 2nd Psychiatry Dept. E.K.P.A.

Abstract
The global economic crisis, which also afflicts the Greek society nowadays, causes multiple upheavals in both individual and community functioning. The life and personality of contemporary man are grounded on employment and financial status; employment contributes to both identity and self-image formation. Therefore, those experiencing massive income cuts face not only obvious practical issues but an equally important ‘symbolic’ collapse. Most researchers agree that loss of employment increases the risk of mental disorders and their adverse effects on physical health. Therefore, it is important that the management of the current economic crisis will rely on services responding to increased social demands for psychological support and intervention as well as social protection. Encephalos 2011, 48(2):54-61.

Key words: Economic crisis, unemployment, mental health.

Introduction

The current global economic crisis that has also hit the Greek society could bring about a host of transformations with major repercussions on both personal and collective levels. The problematic structure and operation of the Greek state enhances the impact of this crisis revealing unresolved issues building up for a considerable amount of time and for which the Greek society has failed to bear the cost of adopting the suggested solutions.Considering the major economic depressions of the last century (the 1929 crash, the Asian financial crisis in the mid-90s) and the periods of financial predicament and poverty experienced by the nationals, there is no doubt that unemployment, insecurity and social exclusion will rise and take their toll on Greek citizens. In fact, Greece belongs to that group of countries whose history is strewn with economic downturns, destruction and warfare. Based on the National Statistical Service of Greece, there has been a rise in the unemployment rate to12.4% (data collected on October 2010) (See table 1).

The unemployment characteristics can be summed up as follows. The unemployment rate (16.1%) for women is significantly higher than that of men (9.7%). According to the age structure of unemployment, the higher unemployment rate hits 24.2% of young people aged 15-29. The rate for young women is 30.6%. In terms of education levels, the unemployment rate among the illiterate population is 19.3%, followed by the higher technical vocational training graduates (15.1%) and the members of the population who have attended only some grades of the primary school (12.4%). Unemployment rate levels among PhD or MA holders (7.5%) and university graduates (9.4%) are considerably lower.

The unemployment rate for young people entering the workplace is 23.7% of the total unemployed population, whereas the long-term unemployment rate (population seeking work for more than 12 months, irrespectively of whether they are entering the workplace for the first time or been employed in the past), is 48.4%. The unemployment rate for the population with foreign citizenship is higher than the rate for Greek citizens (14.0% vs. 12.2%). Furthermore, 74.5% of foreign citizens are financially active, a significantly higher rate than the one that applies for Greek citizens (54.0%).1

With unemployment on the rise, the situation is already highly obscure and the GSEE’s Work Institute expects more than 1,150,000 people to be left without a job and unemployment levels to reach 22% by the end of the year 2011. If one reduces this number to families, one will understandably have trouble finding families without at least one unemployed member in their immediate and wider family.2 At the same time, the social welfare networks report an increase in the number of people seeking support and to meet their basic needs (soup kitchens, accommodation, medicines and medical treatment). Since the end of September, the number of those who turn to the soup kitchens provided by the Church has multiplied, mainly due to the increase of the higher number of Greeks resorting to that solution. Soup kitchens have doubled the meals they offer daily, from 5,000 to 10,000, and that in the Athens region only. Greek citizens represent currently 35%-40% of the poor eating in the soup kitchens, and the age composition of this group is quite revealing of the situation; the majority of the poor people who have resorted to soup kitchens are over 50 and under 70, namely approaching retirement age. This phenomenon is claimed to be associated with the rise in unemployment levels in the said “non-productive” age group whose members have lost their jobs just before retirement.3

In addition, psychological support help lines have recorded a growth in the number of calls regarding psychological problems related to the financial crisis. The Depression Help line of the Antistigma Programme held by the Research University Institute of Mental Health (EPIPSI) has lately recorded an increase in the number of calls related to financial problems and difficulties in the workplace. Around 27% of the calls for psychological support are associated with the financial crisis and the difficulties encountered in the workplace. Unemployment and financial uncertainty are accounted as the most frequent sources of detrimental effects on the callers psychological well-being.

Help line data show that the psychological impact of the financial crisis affects mostly men (65%) and their productive age group in particular (30-45 years old), i.e. the part of the population that usually bears the largest share of financial responsibilities (family and others). Moreover, the lack of job prospects and the unfavourable future employment terms constitute a major source of stress for younger people (18-30 years old). The vast majority of the callers express their inability to find a way out of this impasse and they may even reach the point of considering suicide. In Greece, over the past year the number of suicides had reached 24, whereas more suicidal attempts were made.4 Considering that based on the WHO’s definition of health as “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”5, it is understood that the financial crisis and its repercussions will ultimately take their toll on physical and mental health. The relationship between employment and health indicators has been –and still is -particularly strong. Security at the workplace promotes health, prosperity and job satisfaction, whereas unemployment and insecurity cause stress and increase the risk of illnesses and mental disorders.

“The potential impact of the financial crisis and its upheavals are not to be underestimated. We should not be surprised if there is a rise in suicide rates and mental disorders”, said Dr. Margaret Chan, Director-General of the WHO at 20096,7.

The impact of the financial crisis on mental health

The entire life and personality of modern man is built around his professional and financial status. Work contributes to a significant degree to the definition of one’s identity and self-image. In light of this, notwithstanding the practical problems that one faces when they see their income diminishing or disappearing, they also go through an equally important “symbolic” breakdown. Work and the related social self-esteem affect interaction with others including friends, relatives, partners or children. In addition, the unemployed carry within them deep feelings of inadequacy and weakness. Most researchers tend to agree that the loss of employment increases the risk of mental disorders and their psychosomatic symptoms. Many surveys agree that there is a strong affinity between unemployment and the rise in depression, stress, substance abuse and antisocial behaviour.8 A meta-analysis by Paul & Moser regarding the effects of unemployment on mental health showed that unemployed workers were twice as likely as their employed counterparts to experience psychological problems (34% against 16%). Furthermore, significant differences were found between unemployed and their employed counterparts in key parameters indicating the person’s mental health quality such as anxiety, depression, psychosomatic symptoms, low subjective well-being, low self-esteem etc.

In order to study, prevent and counter the impact of impacts of unemployment and financial downturn on mental health important elements differentiating the consequences of the crisis should be studied. It appears that social stigma and psychological pressure affect men more than women possibly due to the fact that women perform different social roles (child-raising, housekeeping etc).9.10

The socio-economic status plays an equally important role, with low-income individuals reporting higher unemployment rates and greater difficulty to cope with job loss, which in turn affects their emotional mood.11 Moreover, economic migrants are mostly hit by the financial crisis and are at risk of suffering from health problems.12 A recent survey also reinforces the link between poverty and mental disorders. Factors including social discrimination, social exclusion, insecurity, poor education and poverty seem to actively contribute to maximizing the impact of the crisis on lower socio-economic backgrounds.13

Family is a key determinant for the support of a person's mental health in financial crises. Several studies indicate that the spouse or partner may not only support emotionally the unemployed person but also actively contribute to covering household finances.14,15 Furthermore, studies show that age is also a key determinant since middle-aged people suffer more from job loss16. However, there is research evidence that post-studies unemployment also leads to the substantial deterioration of mental health.17

Emotionally vulnerable employees or individuals who already suffer from mental ill health also belong to the population groups that are mostly affected by the economic downturn. In their case, job insecurity and associated stress can have a stressful effect on their already aggravated situation. Furthermore, against the backdrop of the financial crisis, employers tend to become less “tolerant” by detecting the “weakest links” and dismissing them sooner. This creates a vicious circle where mental illness leads to job loss, and where poverty and unemployment causes deterioration of mental illness.18,19

Children are also victims of the financial crisis. Unfavourable circumstances early in their life may modify the structural and functional aspects of the brain’s development, thus contributing to ill mental health in adulthood. The poor socio-economic status of the parents is also associated with a low concentration capacity on the part of the children. Early exposure of the pregnant mother to stress factors due to depression, anxiety or undernourishment increases the Hypothalamic-Pituitary-Adrenal axis activity in the fetus and, as a result, the latter has a modified response to stressful stimuli. Undernourishing the fetus itself may be a key factor as well. For instance, the lack of retinoid acid, a metabolite of vitamin A, has an adverse effect on mental development, the lack of omega-3 fatty acids is associated with greater possibility for the child to present depression and Attention Deficit Hyperactivity Disorder (ADHD), whereas iron deficiency disturbs the process of myelinosis.20 The negative impact of unemployment in terms of mental health seems to be greater in countries with a low level of economic growth, uneven income distribution and poor protection systems of the unemployed population.

In addition, the adverse effects of unemployment are more intensely felt by the long-term unemployed (≥6 months), as against the short-term unemployed.21

As the financial crisis settles in deeper, the predictions for the aggravation of mental health indicators become worse. In the United Kingdom psychotic episodes are expected to triple, incidences of alcohol abuse to double and depressive episodes to double or triple.22 In India, the incidences of individuals seeking psychological help because of the difficulties brought about by the financial crisis are reported to have increased.23 Furthermore, recent reports point to the fact that the suicide rate in Japan due to the ongoing crisis has already risen.24

A study in Chile revealed a strong correlation between the sudden drop in income and the onset of mental disorders, with the symptoms manifesting within 6 months from the income drop.25

Financial debt is a key determinant that predisposes to depression. A study carried out across England, Scotland and Wales showed a clear link between financial debt and poor mental health.26 Furthermore, the first editorials and the first studies or reviews in common and psychiatric journals on the impact of the world recession raise a series of concerns about the health systems’ ability to respond to citizen needs. One of the top journals, the New England Journal of Medicine, has highlighted the pressure exercised on the mental care systems: while requests for prolonged psychiatric hospitalisation decrease, acute episodes and forced hospitalisations are on the rise, as society's tolerance for people with behaviour problems drops in times of recession.27 Against this background of uncertainty and insecurity created as a result of the financial crisis, the state and/or the citizens are unable to find a way out.

“The challenge of the economic downturn for the mental health sector is clear: a likely increase in demand coupled with potentially reduced funding levels, with all the while an emphasis on maintaining quality, efficiency and patient benefit", 1-day Meeting, November 2009, Royal College of Psychiatrists, Mental Health Network–NHS Confederation, London School of Economics and Political Sciences.28

Economic downturn, suicide and mortality rates across the general population

In a study carried out across 26 European countries between 1970 and 2006 the research team investigated how economic changes have affected mortality rates over the past three decades and identified how governments could mitigate their adverse effects. It was found that every 1% of increase in unemployment was associated with a 0.8% rise in suicides at ages younger than 65 years, and with a 0.8% rise in homicides. An increase by more than 3% in unemployment had a greater effect on suicides at ages younger than 65 (an increase >4%) and deaths from alcohol abuse.29

In addition, the study of the impact of the Asian economic recession between 1997 and 1998 showed a marked increase in suicide rates in the southeast Asian countries: in Japan there was an increase by 39%, in Hong Kong by 44%, in Korea by 45%. Similar increases in suicide rates were not witnessed in Taiwan and Singapore because these two countries suffered a smaller impact on their unemployment and GDP levels.30 In a similar study carried out across China, it was found that social changes, including major financial losses at personal level, increased healthcare costs, the weakening of family ties, migration of the population to urban areas in search of work and uneven distribution of income, contribute to the rise in the suicide rate, mainly due to the increase in the population with depressive illnesses, the majority of which remain untreated.31 Similarly, the mass farmer suicides in India after the change of the agriculture policy and the acute drop in income around the mid 1990s are another tangible example of the impact of economic insecurity on mental health.32 Therefore, the economic crisis leads to an important increase in the number of suicides, which is directly associated with a rise in unemployment indicators.33 Nevertheless, general mortality rates of the population appear to be affected as well by the seriousness of the financial situation. A study of the bibliography regarding the mortality rates during periods of economic downturn has shown a direct association of economic crises with the increase in the general mortality indicator rates. Cardiovascular disease death rates increased. There was also an increase in mortality rates due to respiratory infections, chronic liver disease, suicides and homicides. In addition, an increase in infant mortality across all studies was noted during economic crises.34 Exceptionally, death rates for road traffic accidents decreased possibly due to a drop in the number of transports.

Ways of dealing with/preventing the impact of an economic crisis on mental health

There is no doubt that the world recession represents a major challenge for society. It also puts the political and social system under strain and calls upon society to adapt to the new situation. Avoiding the risk of “psychiatrizing” social problems, we should not overlook the effects of social phenomena on a person's mental health.

It is therefore important to shape measures designed to deal with the crisis in the most effective way both individually and as state. Primary care measures should entail the development and implementation of state-funded programs for vocational retraining in order to reintegrate the unemployed into the labour market, and skills development programmes allowing for a greater possibility for flexible employment. Furthermore, policies aimed at gradually changing labour laws, such as job transfers, fewer working hours, leaves at reduced pay, would provide the necessary time and support for the difficult transition.

Secondary measures should promote stress management and ways of dealing with stressful situations through financial management, psychological support and professional orientation mentoring schemes. A key to the secondary prevention measures is the reinforcement of the health system so that it can cope with mental disorders in a timely manner at the primary healthcare level. Also, measures should be focused on the protection of higher risk groups, and all social safety networks should be motivated (athletic groups, associations, charity organizations, church, family, friends) in support of those individuals. The preservation of social coherence is crucial, mainly through the social protection of vulnerable population groups. The example set by Malaysia during the Asian crisis shows us how the preservation of expenses for the social protection of vulnerable population groups and unemployed persons has mitigated the effects of the financial crisis to an important extent.35

Third-level measures should focus on restoring the state of health of the affected individuals and securing financial aid that would ensure the minimum levels of living. Unemployment benefits and active schemes to support the labour market can prove useful tools for the support and reintegration of the affected population. In addition, in a study dealing with the link between public social expenditure and suicide rate across 27 OECD countries from 1980 to 2003 it was found that every 10 dollar increase per person for investments into labour market support schemes led to a mitigation of the effects of unemployment on suicide rates by 0.04%. It appears that social assistance schemes may be crucial for suicide prevention especially in countries affected by a socio-economic crisis.36

Finally, material deprivation should not be enforced unevenly across different social classes but should correspond to the economic figures of each social class. As Freud pointed out as early as 1930, in this situation, a permanent state of discontent will persist in society and may lead to dangerous revolts. If a culture has not gone beyond a point a which the satisfaction of one portion of its participants depends upon the suppression of another, and perhaps, larger portion - and this is the case in all present-day cultures- it is understandable that the suppressed people should develop an intense hostility towards a culture whose existence they make possible by their work, but in whose wealth they have too small a share.37

To conclude, dealing with the current economic recession means that a minimum living standard should be achieved for all citizens in need and a wide social network be organized in support of the individual in times of great distress to remind them that society is built upon social solidarity and collective action.

FOOTNOTES

  1. Έρευνα εργατικού δυναμικού της Ελληνικής Στατιστικής Υπηρεσίας. Δελτίο τύπου 16-12-2010.
  2. Αθηναϊκό Πρακτορείο Ειδήσεων – Μακεδονικό Πρακτορείο Ειδήσεων, 15-1-2011, δήλωση Σάββα Ρομπόλη.
  3. Εφημερίδα Αυγή 12/12/2010.
  4. http://www.tovima.gr/default.asp?pid=2&ct=32&artId=378335&dt=16/01/2011#ixzz1BERFehFc
  5. http://www.who.int/about/definition/en/print.html
  6. WHO. Financial crisis and global health: report of a high-level consultation. Geneva: World Health Organization 2009.
  7. WHO. Health amid a financial crisis: a complex diagnosis. Bull World Health Organ 2009; 87: 1-80.
  8. Murphy GC, Athanasou JA. The effects of unemployment on mental health. J Occup Organ Psychol 1999; 72:83-99.
  9. Kulik L. Jobless men and women: A comparative analysis of job search intensity, attitudes toward employment and related responses. J of Occupational and Organizational Psychology, 2000; 73 487-500.
  10. Shamir, B. Sex differences in psychological adjustment to unemployment and reemployment: A question of commitment, alternatives or finance? Social Problems, 1985; 33, 67-79.
  11. Schaufeli W.B. & van Yperen, N.W. Unemployment and psychological distress among graduates: A longitudinal study. J of Occupational and Organizational Psychology, 1992; 65, 291-305.
  12. Shams M., & Jackson, P.R. The impact of unemployment on the psychological well-being of British Asians. Psychological Medicine, 1994; 24, 347-355.
  13. Patel V, Kleinmann A. Poverty and common health disorders in developing countries. Bulletin of the WHO, 2003.
  14. Vaananen A., Vahtera J., Pentti J., & Kivimaki, M. Sources of social support as determinants of psychiatric morbidity after severe life events: Prospective cohort study of female employees. J of Psychosomatic Research, 2005 ; 58, 459-467.
  15. Leana, C.R., & Feldman, D.C. Gender differences in responses to unemployment. J of Vocational Behavior, 1991; 38, 65-77.
  16. Broomhall, H.S., & Winefield, A.H. A comparison of the affective well-being of young and middle-aged unemployed men matched for length of unemployment. British Journal of Medical Psychology, 1990; 63, 43-52.)
  17. Paul K., & Moser K, Unemployment impairs mental health: Meta-analyses. J of Vocational Behavior, 2009; 74, 264-282.
  18. Ibid.
  19. Aro S, Aro H, Keskimaki I. Socio-economic mobility among patients with schizophrenia or major affective disorder A 17-year retrospective follow-up. Brit J Psych 1995, 166:759-767.
  20. Γιωτάκος, Ο. Οικονομική κρίση και ψυχική υγεία. Ψυχιατρική 2010, 21: 195-204.
  21. Paul K., & Moser K, Unemployment impairs mental health: Meta-analyses. J of Vocational Behavior, 2009; 74, 264-282.
  22. Samaritans. Samaritans report 25% increase in calls as financial crisis hits UK. Medical News Today 2008. http://www.medicalnewstoday.com/articles/123937.php
  23. Patralekha Chatterjee. Economic crisis highlights mental health issues in India. www.thelancet.com Vol 373 April 4, 2009.
  24. Ryall J. Japanese suicides rise as world recession hits country’s businessmen. Telegraph (London), 2009.
  25. Araya R., et al. Education and income: which is more important for mental health? J Epidem Comm Health, 2003, 57: 501-505.
  26. Jenkins R., et al. Debt, income and mental disorder in the general population. Psycholog Med 2008, 38: 1485-1493.
  27. Catalano, R. Health, medical care, and economic crises. New England Journal of Medicine, 2009. 360: 750-751.
  28. http://www2.lse.ac.uk/LSEHealthAndSocialCare/PSSRU/pdf/mental_health_downturn121109.pdf
  29. Stuckler D., Basu S., Suhrcke M., Coutts A., McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. www.thelancet.com 2009 Vol 374 July 25.
  30. Chang S-S, Gunnell D, Sterne JAC, et al. Was the economic crisis 1997-1998 responsible for rising suicide rates in east/southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med 2009; 69: 1322-1331.
  31. Philips et al. Suicide and social change in China Culture. Med Psych 1999, 23: 25-50. 1999
  32. Sundar M. Suicide in farmers in India. Brit J Psych 1999, 175: 585-586.
  33. Uutela A. Economic crisis and mental health. Current Opinion in Psychiatry 2010, 23:127-130
  34. Falagas ME, Vouloumanou EK, Mavros MN, Karageorgopoulos DE. Economic crises and mortality: a review of the literature. Int J Clin Pract, August 2009, 63, 8, 1128-1135.
  35. Hopkins S. Economic stability and health status: evidence from east Asia before and after the 1990s economic crisis. Health Policy 2006, 75: 347-357.
  36. Park Y., et al. The Association between public social expenditure and suicides: evidence from OECD countries. J Prev Med Pub Health 2009, 123-129.
  37. Φρόυντ Σ. Ο πολιτισμός πηγή δυστυχίας. Αθήνα: Επίκουρος, 1994.

REFERENCES

  1. Έρευνα εργατικού δυναμικού της Ελληνικής Στατιστικής Υπηρεσίας. Δελτίο τύπου 16-12-2010.
  2. Αθηναϊκό Πρακτορείο Ειδήσεων – Μακεδονικό Πρακτορείο Ειδήσεων, 15-1-2011, δήλωση Σάββα Ρομπόλη.
  3. Εφημερίδα Αυγή 12/12/2010.
  4. http://www.tovima.gr/default.asp?pid=2&ct=32&artId=378335&dt=16/01/2011#ixzz1BERFehFc
  5. http://www.who.int/about/definition/en/print.html
  6. WHO. Financial crisis and global health: report of a high-level consultation. Geneva: World Health Organization 2009.
  7. WHO. Health amid a financial crisis: a complex diagnosis. Bull World Health Organ 2009; 87: 1-80.
  8. Murphy GC, Athanasou JA. The effects of unemployment on mental health. J Occup Organ Psychol 1999; 72:83-99.
  9. Kulik L. Jobless men and women: A comparative analysis of job search intensity, attitudes toward employment and related responses. J of Occupational and Organizational Psychology, 2000; 73 487-500.
  10. Shamir, B. Sex differences in psychological adjustment to unemployment and reemployment: A question of commitment, alternatives or finance? Social Problems, 1985; 33, 67-79.
  11. Schaufeli W.B. & van Yperen, N.W. Unemployment and psychological distress among graduates: A longitudinal study. J of Occupational and Organizational Psychology, 1992; 65, 291-305.
  12. Shams M., & Jackson, P.R. The impact of unemployment on the psychological well-being of British Asians. Psychological Medicine, 1994; 24, 347-355.
  13. Patel V, Kleinmann A. Poverty and common health disorders in developing countries. Bulletin of the WHO, 2003.
  14. Vaananen A., Vahtera J., Pentti J., & Kivimaki, M. Sources of social support as determinants of psychiatric morbidity after severe life events: Prospective cohort study of female employees. J of Psychosomatic Research, 2005 ; 58, 459-467.
  15. Leana, C.R., & Feldman, D.C. Gender differences in responses to unemployment. J of Vocational Behavior, 1991; 38, 65-77.
  16. Broomhall, H.S., & Winefield, A.H. A comparison of the affective well-being of young and middle-aged unemployed men matched for length of unemployment. British Journal of Medical Psychology, 1990; 63, 43-52.)
  17. Paul K., & Moser K, Unemployment impairs mental health: Meta-analyses. J of Vocational Behavior, 2009; 74, 264-282.
  18. Ibid.
  19. Aro S, Aro H, Keskimaki I. Socio-economic mobility among patients with schizophrenia or major affective disorder A 17-year retrospective follow-up. Brit J Psych 1995, 166:759-767.
  20. Γιωτάκος, Ο. Οικονομική κρίση και ψυχική υγεία. Ψυχιατρική 2010, 21: 195-204.
  21. Paul K., & Moser K, Unemployment impairs mental health: Meta-analyses. J of Vocational Behavior, 2009; 74, 264-282.
  22. Samaritans. Samaritans report 25% increase in calls as financial crisis hits UK. Medical News Today 2008. http://www.medicalnewstoday.com/articles/123937.php
  23. Patralekha Chatterjee. Economic crisis highlights mental health issues in India. www.thelancet.com Vol 373 April 4, 2009.
  24. Ryall J. Japanese suicides rise as world recession hits country’s businessmen. Telegraph (London), 2009.
  25. Araya R., et al. Education and income: which is more important for mental health? J Epidem Comm Health, 2003, 57: 501-505.
  26. Jenkins R., et al. Debt, income and mental disorder in the general population. Psycholog Med 2008, 38: 1485-1493.
  27. Catalano, R. Health, medical care, and economic crises. New England Journal of Medicine, 2009. 360: 750-751.
  28. http://www2.lse.ac.uk/LSEHealthAndSocialCare/PSSRU/pdf/mental_health_downturn121109.pdf
  29. Stuckler D., Basu S., Suhrcke M., Coutts A., McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. www.thelancet.com 2009 Vol 374 July 25.
  30. Chang S-S, Gunnell D, Sterne JAC, et al. Was the economic crisis 1997-1998 responsible for rising suicide rates in east/southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med 2009; 69: 1322-1331.
  31. Philips et al. Suicide and social change in China Culture. Med Psych 1999, 23: 25-50. 1999
  32. Sundar M. Suicide in farmers in India. Brit J Psych 1999, 175: 585-586.
  33. Uutela A. Economic crisis and mental health. Current Opinion in Psychiatry 2010, 23:127-130
  34. Falagas ME, Vouloumanou EK, Mavros MN, Karageorgopoulos DE. Economic crises and mortality: a review of the literature. Int J Clin Pract, August 2009, 63, 8, 1128-1135.
  35. Hopkins S. Economic stability and health status: evidence from east Asia before and after the 1990s economic crisis. Health Policy 2006, 75: 347-357.
  36. Park Y., et al. The Association between public social expenditure and suicides: evidence from OECD countries. J Prev Med Pub Health 2009, 123-129.
  37. Φρόυντ Σ. Ο πολιτισμός πηγή δυστυχίας. Αθήνα: Επίκουρος, 1994.