Depression and the recession

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By Dr Olivia McElwee*

These days it seems that no matter where we look, we are confronted with the doom and gloom of economic recession. Newscasters and front page headlines are, on an almost daily basis, delivering notice of yet more jobs lost. And what can we expect in the near future; more doom and gloom to come, it would seem.

The financial stress on individuals, in addition to the general negativity felt by the wider community, is already having a huge impact on the mental health of our country.

The mental health of a society is based on key certainties, which are eroded in times such as these.

We are faced with endless uncertainty at present; uncertainty in the job sector -  gone is the concept of a job for life, uncertainty in our banking sector, concern over energy reserves resulting in fluctuating oil prices, uncertainty over public finances etc.

The media is partly responsible for propagating this uncertainty. The view projected is a negative one and the picture presented is very black and white.

The portrayal and reporting of an economic recession can lower the general mood of the country people are naturally affected on an individual basis too.  Taking redundancy as an example; how does losing one’s job affect an individual?

The attainment of basic physical and material needs is essential in order to move forward with the attainment of more complex psychological needs and aspirations.

With that in mind, we can see how redundancy may lead to significant stress. Being made unemployed, is to be cast adrift at sea. An important avenue of social interaction is terminated and there is a huge sense of abandonment and a loss of that sense of belonging.

In addition, in today’s world, people’s sense of identity is very much enmeshed in their work.  Their self-esteem and sense of worth is often determined by how successful they are in the workplace.

Now more than ever, what we do is tied up with who we are. People today, of they are lucky enough to still have jobs, work longer hours. One’s occupation has always been important of course. It fulfils a fundamental need and provides us with challenges and a sense of achievement. It also provides routine and a day to day focus. 

However, the pursuit of material success has arguably distorted people’s appreciation of real priorities and perhaps the present economic slowdown will encourage a greater reflection and re-evaluation of what is truly important in life.

It is likely that healthcare professionals and in particular GPs will see a rise in the number of people seeking help for symptoms of general stress, anxiety and depression.

We will see the effects of economic stress and unemployment across all age ranges and members of society. In school leavers who cannot find work, it may lead to a retardation of personal growth and a continuation of the dependency faced at school.

In those retired or near retirement, there exists great concern for the future. Many have pensions tied up in shares and have suffered substantial losses in recent times.

How prepared are we as doctors to assist individuals in such distress?

People stressed by the recession may be suffering from adjustment disorder, which is characterised by a variety of clinically significant behavioural or emotional symptoms occurring as a result of a triggering event or stressor. It may be associated with - depressed mood; anxiety; or disturbance of conduct.

This disworder usually occurs within three months of the stressor. The condition may become chronic (lasting more than six months) should the stressor be chronic or the consequences and impact of the initial event be long-lasting.

Making the diagnosis of adjustment disorder is important as these patients generally benefit from some form of counselling. Rapid identification can prompt early psychological intervention that enhances the patient's quality of life or, at the very least, prevents further erosion of his or her ability to function.

Approximately three in ten people suffer from depression, with twice as many women as men presenting with symptoms warranting clinical intervention.

There is no doubt that healthcare professionals will see an increase in the disorder, given that the background social and monetary environment has an impact on the incidence with a link between depression and financial strain and damage to sense of self.

Research suggests that while employment status and financial strain are causally related to depression, income is not.  In other words, a low income earner is not by that fact more prone to depression but should financial strain co-exist, his risk would increase.

Not only can the act of being made redundant lead to depression  but the cascade of secondary stressors, such as financial insecurity and relationship strain which may follow on from it, can present as much a risk to the mental health of the job seeker as the job loss itself.

Secondary stressors also have an important impact on the mental health of the partner. Some research suggests that when a man loses a job, the associated stresses of unemployment and financial strain are taken on as common burdens by both members of the couple, whereas when a woman loses a job, she may be more likely to face those burdens alone.

There is a potential for drug or alcohol abuse in those with no known documented history, especially in instances of redundancy where drugs and alcohol provide a perceived escape from the reality of the situation. 

Cocaine use among Ireland’s middle classes took off hugely during the years of the Celtic tiger. Numerous redundancies are occurring across all socio-economic groups and healthcare professionals should be alert to the fact that individuals may no longer have the same level of income to sustain a costly habit thus a crisis may ensue.

In the Great Depression of the early 1930s, 13 million people in the United States lost their jobs and the income of an average American family dropped by 40% yet the suicide rate only increased from 14 to 17 per 100,000.

We are familiar with stories of bankers jumping to their deaths from their office windows, after sustaining huge losses in the Wall Street Crash of 1929. However few of these stories are based on fact.

Less than twenty Wall Street bankers are thought to have actually committed suicide at work immediately following the Crash and approximately one hundred professionals involved in the stock markets are believed to have taken their own lives.

The majority of the 23,000 Americans who committed suicide in the year following the Crash were ordinary people who suffered indirectly from the financial fallout. Examples would include the farmers who lost their farms, individuals who lost their jobs or savings, and entrepreneurs who lost their businesses.

We must however, be aware of the risk factors for suicide in our patient population. As well as unemployment, other risk factors include male gender, those living alone, divorced or widowed patients, those with a chronic physical illness, those with a previous psychiatric history, those with recent admission to a psychiatric hospital, patients with a history of attempted suicide or self harm in the past and patients who abuse alcohol or drugs.

The approach to the management of a patient presenting with symptoms thought to be related to recent financial strain could incorporate many of the following:

1. Giving general lifestyle and health advice such as taking more exercise, drinking less coffee, getting more sleep, engaging in some form of meditation or relaxation like yoga or listening to classical music. Quitting cigarettes, cutting down on alcohol consumption and following a better diet are not only beneficial from a health point of view but will also save money.

2. Encouraging the patient to see their circumstances as an opportunity rather than a crisis by reframing the situation and identifying the positives.

For example, in a patient made recently unemployed, one could point out that this may be a natural opportunity to pursue something they’ve always wanted to do. It may be a good time to do a course or attend classes in a new subject. Redundancy may provide an opportunity for one’s spouse to spend more time with their family while giving their partner a chance to re-enter the workplace. It offers a natural time for a reality check and a period to prioritise what’s important.

3. It may be helpful to discuss, where a patient interested in retraining, might start to make enquiries - for example Fas Ireland or night courses in the local vocational school or adult learning centre.

4. Referring to local counselling services may be appropriate. 

5. Doctors and health professionals can tactfully discuss the role of local charitable organisations such as St. Vincent de Paul or Barnardos. 

6. It may also be fitting to advise a patient to contact their local Money Advice and Budgeting Service (MABS). MABS is a national, free, confidential and independent service for people in debt or in danger of getting into debt and a helpline exists.

7. Antidepressant drugs can be prescribed should the doctor feel they are indicated.

8. The healthcare professional needs to assess whether the patient at risk of harming him or herself and should liaise with psychiatric services/crisis intervention services if appropriate. 

9. It may be fitting to discuss the option of working abroad, which may be looked upon more favourably as other economies recover more quickly than ours.

10. In these difficult times, we will likely see an increased reliance on parental support. Patients may have a son or daughter whom they are concerned about, and as parents may choose to pass on some of their inheritance to their children at an earlier stage (hoping to alleviate current financial strain) rather than waiting until their death to do so.  It may be advisable to suggest consultation with a solicitor in these circumstances.

The goal must be to assist people in difficulty due to the recession in dignified manner using a holistic approach, aiming to prevent crises and emergency psychiatric presentations. Counselling and robust psychological support services will be seen as crucial components in achieving this.

In the midst of this crisis, we must also advocate politically for the retention of essential services , particularly in the area of retraining, not only for the health of patients but to allow them fulfil their potential.


*Olivia McElwee is a GP registar with the TCD/HSE GP training scheme. This article first appeared in 'Forum', the journal of the Irish College of General Practitioners.

Anonymous  Posted: 15/05/2009 08:28

It seems that at a time when people need health services even more, funding is being cut back for them. I think it's hardest of all on a household where both parties in the couple have lost their job. At least when one is working there is an income coming in to keep things going.

Chrissie  Posted: 16/05/2009 00:07

This article where they talk of the 1929 recession-way back in January this year I happened to be watching a movie on TV when next came on was a true life story from 3 american survivors of the 1929 recession what they each said what they witnessed as children was terrible. I pondered on this knowing we were heading towards another recession - my Husband was in Hospital at that time while I was watching this. He has worked for years on end, and with the fall he had he needed orthopaedic surgery and now knows he will never be able to return to work. I survived a Brain Haemorrhage when our youngest was 3 years old. I worry for my two grown up children with mortgages, and they don't lose their jobs. I worry for my 3 grandchildren. Way back in our eighties recession my Husband was lucky to have kept his job, I was not sick then and we barely managed I missed Peter to pay Paul. Always brought my children to our GP when they were sick, but myself and him would just let things go and not spend for doctors fees for ourselves when we needed too. I have learned that our Republic of Ireland is the worst Country that will suffer most with our World Wide Recession. Our youngest child who is in 3rd level educatiion - well we cannot afford to send her back this coming September. Our income is 204.30 for him and mine is 209.80 per week for invalidity book. In two weeks or so our Daughter will be going down to social welfare to sign on and because she is under 20 years old she will get 102.15 euros per week which will take weeks to process. Our mortgage is not fully paid yet, we have almost 8 years to go to finish this. Even last August our other Son who lived in private rental with 3 other occupants in a 4 bedroom house lost his job. He moved in with us for 3 months, thankfully he got another job in October he's an IT technician, he's living in rented accommadation since last early December, but he's only there for as long as he has his job. I just give my story of our experience of this Recession, don't look for pity I would say there are more out there to tell their story, and as we all know we are only months into this recession. What will become of our young and the road they go down. I realise even those who are working are being penalised by their high levies, and there's more to come in December since our Finance Minister said he's raising taxable rates for 2010 and not reducing present levies. They are even making our OAPs suffer who were the backbone of our Republic of Ireland by taking away their bonus payment for Christmas and lesser home help. How can they do this to the most vunerable?  I hope our forthcoming local election and European Election in June that people will turn out in droves and vote, vote, vote, to try change the situation we find ourselves in - 'though it will take time. Chrissie I write this from my heart so that all the young will not suffer more financially than they already are

Anonymous  Posted: 18/05/2009 11:37

Hi Chrissie, it's a daming indictment of our society if your youngest is forced out of education due to lack of money. Given yoiur household incoke I woulod say she would be well entitled to a grant. Also both the university and your local credit union may have an education bursary for cases like this. It would be well worth her looking into both options.

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