Sunday, May 19, 2013

If You Want to Reduce Suicide, Focus on the Economy

Ross Douthat is concerned that "loneliness" may be behind an increase in the suicide rate among middle aged men... a classic case of missing the forest for the trees. You would think this part would clue Douthat in:
This trend is striking without necessarily being surprising. As the University of Virginia sociologist Brad Wilcox pointed out recently, there’s a strong link between suicide and weakened social ties: people — and especially men — become more likely to kill themselves “when they get disconnected from society’s core institutions (e.g., marriage, religion) or when their economic prospects take a dive (e.g., unemployment).” That’s exactly what we’ve seen happen lately among the middle-aged male population, whose suicide rates have climbed the fastest: a retreat from family obligations, from civic and religious participation, and from full-time paying work.
But you can see he's already on the wrong track by the end of the paragraph. That is, the problem is not about a retreat from family, community and work. It's about the carpet being pulled out from under you.

You would think it was a state secret that the group at highest risk of suicide was middle class men (particularly white men), and that risk of suicide is strongly associated with three stressors: job loss, loss of family and poor health. Contrary to Douthat's assumption, there's not a higher suicide risk if you're single versus married - but divorce is a risk factor.

In our culture, our identity is wrapped up in the work we do. One of the first questions you're likely to be asked when you meet somebody is "Where do you work" or "What kind of work do you do". The factors also tend to go hand-in-hand. Poor health can lead to the loss of employment, financial stress resulting from loss of employment (or from poor health) can lead to divorce. When somebody's self image is built around job and family and he feels that he's irretrievably lost his economic future and his family, that's a huge psychological blow.

Douthat builds his argument in part on a fiction, that we're dealing with "structural unemployment". I've taken some issue with those who argue that there's nothing structural about our unemployment situation, but the type of thing they're talking about (the ability to return to full employment) and the type of thing I'm talking about (the ability of somebody who has lost employment to get back onto a similar income and career path) are two different things. If Douthat believes that there's something new about the problems men have if they're displaced from the workplace during or after their late forties, he hasn't been paying attention. Not even to the content of the newspaper for which he writes:
Unemployment is almost always a traumatic event, especially for older workers. A paper by the economists Daniel Sullivan and Till von Wachter estimates a 50 to 100 percent increase in death rates for older male workers in the years immediately following a job loss, if they previously had been consistently employed. This higher mortality rate implies that a male worker displaced in midcareer can expect to live about one and a half years less than a worker who keeps his job.

There are various reasons for this rise in mortality. One is suicide. A recent study found that a 10 percent increase in the unemployment rate (say from 8 to 8.8 percent) would increase the suicide rate for males by 1.47 percent. This is not a small effect. Assuming a link of that scale, the increase in unemployment would lead to an additional 128 suicides per month in the United States. The picture for the long-term unemployed is especially disturbing. The duration of unemployment is the dominant force in the relationship between joblessness and the risk of suicide.

Joblessness is also associated with some serious illnesses, although the causal links are poorly understood.
More academically,
Suicide rates among both men and women aged 35–64 years increased substantially from 1999 and 2010. This finding is consistent with a previous study that showed a notable increase in the overall suicide rate among middle-aged adults relative to a small increase in suicide rates among younger persons and a small decline in older persons during a similar period. The increases were geographically widespread and occurred in states with high, as well as average and low suicide rates. By race/ethnicity, the increases were highest and statistically significant only among whites and American Indian/Alaska Natives, widening the racial/ethnic gap in suicide rates....

Possible contributing factors for the rise in suicide rates among middle-aged adults include the recent economic downturn (historically, suicide rates tend to correlate with business cycles, with higher rates observed during times of economic hardship); a cohort effect, based on evidence that the "baby boomer" generation had unusually high suicide rates during their adolescent years; and a rise in intentional overdoses associated with the increase in availability of prescription opioids.
In a loosey-goosey sort of sense, one court argue that Douthat has a point. That if people who were suicidal could break out of their mindset, reconnect with their communities, and find peace and joy in their lives, they would no longer be suicidal. But that would be to assume that depression and suicide are the results of a rational thought process rather than cognitive distortion, and that somebody who is suicidally depressed is well-positioned to make significant life changes. Sometimes in response to a suicide you hear, "I don't understand, he seemed so happy that day" - the result of a confusion of the immense relief that can come from the decision to commit suicide with an emergence from depression. When severely depressed individuals receive treatment, you have to be very careful during their early recovery because in some cases the only thing holding them back from suicide is lacking the cognitive energy to carry out their plan. This cartoon series, I think, does a pretty good job of illustrating depression - but that freedom depicted at the end can be (and in the author's case, was) dangerous.

Douthat shares a non-suicidal author's account of how he reconnected with his small hometown due to his sister's terminal illness, and extrapolates,
Too often, and probably increasingly, not enough Americans will have what the Lemings had — a place that knew them intimately, a community to lean on, a strong network in a time of trial.

And absent such blessings, it’s all too understandable that some people enduring suffering and loneliness would end up looking not for help or support, but for a way to end it all.
It seems that Douthat is looking for a simple solution to the issue of suicide that ties into his conceit that a simple, small town lifestyle is somehow superior to... the way he lives his own life. As if anybody can find peace, contentment and community simply by moving to small town, rural America. As if small town, rural America would be unchanged if we all moved there. As if that's even possible. As if you can't find community in a city. As if suicide rates weren't higher in the less urbanized parts of the nation.

If you care about reducing suicide, you should be calling for government policies to help restore full employment. You should be advocating programs to help people deal with job loss and regain decent employment. You should be concerned about the quality and availability of mental health care. Pretending that all will be well if people return to the type of community seen in states with above-average suicide rates? Probably not helpful.

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