Impact of recent economic problems on mental health in Ireland.

The effect, if any, of recent economic problems on mental health in the Republic of Ireland is not fully clear. Rates of suicide increased slightly between 2006 and 2011, and there was a notable increase in 2011 itself. Rates of psychiatric admission continued to fall, however, in line with national mental health policy. Use of sedative and tranquilliser medications (but not antidepressants) increased, although use in the Republic of Ireland remains substantially lower than in Northern Ireland. Mean self-rated happiness in Ireland declined steadily and significantly between 2005 and 2012. In 2009, as economic problems deepened, satisfaction with income replaced satisfaction with health as the strongest correlate of happiness in Ireland. By 2011/12, however, none of the traditional correlates of happiness retained an independent association with happiness. Overall, these trends suggest that suicide prevention strategies will be increasingly important for Ireland in future years. Active labour-market programmes to address unemployment may also play an important role in suicide prevention. Rates of mental illness and medication usage in the community merit further study. The solution to declining happiness levels may elude purposive description but this trend is likely to reverse as Ireland's economic prospects improve.

Over the past decade, the Republic of Ireland experienced a dramatic economic boom followed by equally dramatic economic problems (Doherty & Kelly, 2013). In 2003, Ireland’s unemployment rate was 4% but by 2011 it had risen to 14%, as a result of a collapse in Irish property prices and problems in the world economy. In 2007, Ireland’s gross domestic product (GDP) stood at €189 billion but by 2009 it had fallen to €159 billion. In 2010, Ireland had to accept economic assistance from the International Monetary Fund, the European Union and the European Central Bank. In addition, Ireland became subject to relentless scrutiny by international media, most of it highly critical (Lewis, 2011).

Have these events affected mental health in Ireland? It is difficult to answer this question definitively, owing to a paucity of research. Nonetheless, some data are available in relation to specific indices of mental health, including rates of suicide, rates of admission to in-patient psychiatric care and medication usage, and studies of population happiness. Notwithstanding their limitations, these data can help identify emergent trends and indicate key needs to be addressed in future years.

Suicide in Ireland

In 2011, there were 525 suicides in Ireland, which yields a rate of 11.4 suicides per 100 000 population per year (Central Statistics Office, 2012). This is slightly higher than the rate of 10.8 per year reported in 2006, before Ireland’s recent economic problems became apparent. The rate of suicide may, however, be changing quite rapidly: the 525 suicides recorded in 2011 represent an increase of 7% on the previous year, suggesting that Ireland’s economic problems may have a delayed effect on suicide rates.

Ireland’s rate of unemployment is especially relevant to the rate of suicide. Unemployment increased from 4% in 2006 to 14% in 2011. At European level, there is strong evidence that every 1% increase in unemployment is associated with a 0.79% rise in suicides among those aged under 65 years (Stuckler et al, 2009). Data from Ireland confirm that, prior to recent economic problems, unemployment was associated with a two- to threefold increased risk of male suicide and undetermined death, and a four- to sixfold increase in risk in females (Corcoran & Arensman, 2011). Against this backdrop, it is logical to hypothesise that the recent increase in unemployment in Ireland may be associated with an increase in suicide.

Ireland already has a National Office for Suicide Prevention, which, in 2011, allocated an additional €1 million to 22 new projects aimed at suicide prevention (National Office for Suicide Prevention, 2012). Over 3500 people received training in applied suicide intervention skills and nearly 5000 underwent suicide alertness training. If current trends in unemployment and suicide continue, these kinds of initiative are likely to be of increasing importance in years to come.

Admission to psychiatric care and medication usage

More information on trends in mental illness can be derived from national data on admissions to in-patient psychiatric care. In recent decades, Ireland’s mental health services have moved towards community-based models of care, in line with A Vision for Change, Ireland’s national mental health policy (Expert Group on Mental Health Policy, 2006). Consistent with this, the rate of admission to in-patient psychiatric care has declined by 20% over the past decade: in 2002 there were 23 677 admissions to in-patient psychiatric care and by 2011 this had fallen to 18 992 (Daly & Walsh, 2012). This trend remains strong, despite Ireland’s economic problems: in 2010 the rate of psychiatric admission was 462.7 per 100 000 population; in 2011 this fell to 413.9.

Rates of admission, however, reflect just one parameter of mental healthcare. It is possible that increased rates of mental illness, if they exist, are not reflected in admission rates, owing to the move towards community services. Rates of medication use may provide insights into rates of mental illness in the broader community. Data here present a mixed picture: in 2010/11, 6.5% of Irish adults said they had used sedatives and tranquillisers over the previous year, compared with 4.7% in 2006/07; this was a statistically significant increase (National Advisory Committee on Drugs & Public Health Information and Research Branch, 2012). Rates of antidepressant use, however, remained steady, at 4.4% in 2006/07 and 4.8% in 2010/11.

Interestingly, in Northern Ireland (which is part of the UK) the rate of antidepressant use over the previous year is almost three times that in the Republic of Ireland (12.0%, compared with 4.8%) and the rate of sedative and tranquilliser use is almost double (11.0%, compared with 6.5%). These contrasts both require further study.

Happiness

Recent years have seen increased interest in the study of happiness as an index of national wellbeing. In Ireland, we have traditionally rated ourselves as very happy: in 1998, our self-rated happiness was the highest among 28 countries surveyed worldwide, with 44% self-rating as ‘very happy’, compared with 18% in West Germany (Dorn et al, 2007).

In order to investigate the effects of Ireland’s recent economic problems on happiness, we used data from the European Social Survey (ESS), collected between 2003 and 2009 (Doherty & Kelly, 2013). The ESS measures individual happiness based on the question ‘Taking all things together, how happy would you say you are?’ (Jowell & Central Coordinating Team, 2007) (see http://www.europeansocialsurvey.org). Respondents rate their own happiness between 0 (extremely unhappy) and 10 (extremely happy).

We found that, as Ireland’s economic problems became apparent, mean self-rated happiness decreased slightly but steadily, from 7.9 in 2005 (n = 2274) to 7.7 in 2007 (n =1794; P <0.001) and 7.5 in 2009 (n =1764; P < 0.001) (Fig. 1). For the present paper, we went on to analyse the most recent ESS data-set, collected between September 2011 and January 2012 (n = 2570), and found that mean happiness in Ireland has continued to fall, and now stands at 6.8, a further significant reduction on previous years (P <0.001).

Fig. 1

Self-rated happiness in Ireland, 2005–11. Data are derived from the European Social Survey, 2005–11/12 (Jowell & Central Coordinating Team, 2007) (http://www.europeansocialsurvey.org). Respondents rated their happiness between 0 (extremely unhappy) and 10 (extremely happy) in response to the question ‘Taking all things together, how happy would you say you are?’ The figure is based in part on Doherty & Kelly (2013)

There has also been a substantial shift in the key correlates of happiness over this period. We studied relationships between happiness and age, gender, employment, community trust, religiosity, satisfaction with income, satisfaction with health and satisfaction with democracy (Doherty & Kelly, 2013). In 2005, satisfaction with health was the strongest correlate of happiness in Ireland but by 2009, as economic problems deepened, satisfaction with income became the strongest correlate.

The most recent data demonstrate further change in this pattern: multi-variable modelling reveals that in 2011/12 none of the previous predictors of happiness predicted it any longer, after controlling for the others (P > 0.05 for all potential correlates examined). Therefore, while happiness in Ireland has fallen steadily since 2005, the key correlates or predictors of happiness have also undergone substantial change, resulting in substantially altered levels and correlates of happiness in Ireland.

Conclusions

Both the international and Irish literatures draw clear links between unemployment and suicide. In light of the increase in Ireland’s unemployment rate (from 4% in 2006 to 14% in 2011) and the 7% increase in suicides between 2010 and 2011, initiatives to prevent suicide should now take on an added urgency. Active labour market programmes to address unemployment may also play an important role in suicide prevention (Stuckler et al, 2009).

While Ireland’s economic problems did not see increased rates of admission to in-patient psychiatric care, this does not mean that the economic crisis has not affected mental health. There is a paucity of data on rates of presentation to out-patient and primary care. Moreover, use of sedatives and tranquillisers, although not antidepressants, has increased. This area merits further study, not least because the apparent increase in suicide following Ireland’s economic problems emerged only in 2011, some years after Ireland’s economic problems commenced. Extrapolating from this trend, there may well be similar increases in presentations with depression and anxiety disorders in primary care in future years (McElwee, 2009).

Finally, self-rated happiness in Ireland has declined significantly. The increasingly close association between happiness and income, as opposed to health, between 2005 and 2009 likely reflected the effects of Ireland’s economic problems on employment rates and income. The more recent finding that happiness no longer demonstrates independent relationships with any of its traditional predictors may reflect the transitional situation in which Ireland finds itself, as the economy stabilises and Ireland finds its feet in a new and altered economic world.

Alternatively, the absence of any robust, independent predictors of happiness at this time may simply reflect the idea that happiness, in the end, can be neither fully explained nor purposively sought. Perhaps, in words commonly attributed to American philosopher Henry David Thoreau (1817–62), ‘happiness is like a butterfly: the more you chase it, the more it will elude you, but if you turn your attention to other things, it will come and sit softly on your shoulder’.