The Impact of Unemployment on Health: A Review of the Evidence

Abstract

To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation.
MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications.
Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies.
Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa).
Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors.
Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.

Full text

[
systematic
review
*
examen
critique
systematique
]
THE
IMPACT
OF
UNEMPLOYMENT
ON
HEALTH:
A
REVIEW
OF
THE
EVIDENCE
Robert
1.
Jin,
MD,
MHSc,
CCFP,
FRCPC;
Chandrakant
P.
Shah,
MD,
FRCPC;
Tomislav
J.
Svoboda,
MSc,
MD
Objective:
To
review
the
scientific
evidence
supporting
an
association
between
unemployment
and
adverse
health
outcomes
and
to
assess
the
evidence
on
the
basis
of
the
epidemiologic
criteria
for
causation.
Data
sources:
MEDLINE
was
searched
for
all
relevant
articles
with
the
use
of
the
MeSH
terms
"unemploy-
ment,"
"employment,"
"job
loss,"
"economy"
and
a
range
of
mortality
and
morbidity
outcomes.
A
sec-
ondary
search
was
conducted
for
references
from
the
primary
search
articles,
review
articles
or
published
commentaries.
Data
and
definitions
of
unemployment
were
drawn
from
Statistics
Canada
publications.
Study
selection:
Selection
focused
on
articles
published
in
the
1980s
and
1990s.
English-language
reports
of
aggregate-level
research
(involving
an
entire
population),
such
as
time-series
analyses,
and
studies
of
individual
subjects,
such
as
cross-sectional,
case-control
or
cohort
studies,
were
reviewed.
In
total,
the
authors
reviewed
46
articles
that
described
original
studies.
Data
extraction:
Information
was
sought
on
the
association
(if
any)
between
unemployment
and
health
outcomes
such
as
mortality
rates,
specific
causes
of
death,
incidence
of
physical
and
mental
disorders
and
the
use
of
health
care
services.
Information
was
extracted
on
the
nature
of
the
association
(positive
or
negative),
measures
of
association
(relative
risk,
odds
ratio
or
standardized
mortality
ratio),
and
the
direction
of
causation
(whether
unemployment
caused
ill
health
or
vice
versa).
Data
synthesis:
Most
aggregate-level
studies
reported
a
positive
association
between
national
unemploy-
ment
rates
and
rates
of
overall
mortality
and
mortality
due
to
cardiovascular
disease
and
suicide.
How-
ever,
the
relation
between
unemployment
rates
and
motor-vehicle
fatality
rates
may
be
inverse.
Large,
census-based
cohort
studies
showed
higher
rates
of
overall
mortality,
death
due
to
cardiovascular
dis-
ease
and
suicide
among
unemployed
men
and
women
than
among
either
employed
people
or
the
gen-
eral
population.
Workers
laid off
because
of
factory
closure
have
reported
more
symptoms
and
illnesses
than
employed
people;
some
of
these
reports
have
been
validated
objectively.
Unemployed
people
may
be
more
likely
than
employed
people
to
visit
physicians,
take
medications
or
be
admitted
to
gen-
eral
hospitals.
A
possible
association
between
unemployment
and
rates
of
admission
to
psychiatric
hos-
pitals
is
complicated
by
other
institutional
and
environmental
factors.
Conclusions:
Evaluated
on
an
epidemiologic
basis,
the
evidence
suggests
a
strong,
positive
association
be-
tween
unemployment
and
many
adverse
health
outcomes.
Whether
unemployment
causes
these
ad-
verse
outcomes
is
less
straightforward,
however,
because
there
are
likely
many
mediating
and
con-
founding
factors,
which
may
be
social,
economic
or
clinical.
Many
authors
have
suggested
mechanisms
of
causation,
but
further
research
is
needed
to
test
these
hypotheses.
Objectif:
Revoir
les
preuves
scientifiques
qui
associent
chomage
et
bilan
de
sante
negatif
et
les
evaluer
en
fonction
des.criteres
epidemiologiques
pour
en
determiner
la
relation
de
causalite.
Sources
des
donnees:
On
a
fait
une
recherche
dans
MEDLINE
pour
y
trouver
tous
les
articles
pertinents
contenant
les
termes
MeSH
((chomage>>,
<<emploi>>,
<<perte
d'emploi>>,
<<economie>>
et
un
eventail
de
re-
sultats
de
mortalite
et
de
morbidite.
On
a
effectue
une
recherche
secondaire
des
references
provenant
des
articles,
des
examens
critiques
ou
des
commentaires
publies
releves
ha
a
premiere
recherche.
Les
donnees
et
les
definitions
du
ch6mage
proviennent
de
publications
de
Statistique
Canada.
.-
For
prescribing
information
see
page
705
CAN
MED
ASSOC
529
Dr.
Jin
is
a
medical
specialist
with
the
Occupational
Health
Section
(Medical
Services
Department)
of
the
Workers'
Compensation
Board
of
British
Columbia,
Vancouver,
BC.
Dr.
Shah
is
a
professor
in
the
Faculty
of
Medicine,
departments
of
Preventive
Medicine
and
Biostatistics,
Paediatrics,
Health
Administration
and
Family
and
Community
Medicine,
University
of
Toronto,
and
is
also
associated
with
the
Hospital
for
Sick
Children,
Toronto,
Ont.
Mr.
Svoboda
is
a
resident
in
community
medicine
at
the
University
of
Toronto,
Toronto,
Ont.
Reprint
requests
to:
Dr.
Robert
Jin,
Workers'
Compensation
Board
of
British
Columbia,
Occupational
Health
Section,
6951
Westminster
Hwy.,
Richmond
BC
V7C
1C6;
fax
604
279-7697
.-
For
prescribing
information
see
page
705
CAN
MED
ASSOC
J
*
SEPT.
1,
1995;
153
(5)
529

Selection
d'etudes
:
La
selection
a
porte
sur
les
articles
publies
dans
les
annees
1980
et
1990.
On
a
revu
les
rapports
en
anglais
d'etudes
generales
(portant
sur
une
population
complete),
comme
les
analyses
de
series
chronologiques,
et
les
etudes
de
sujets
individuels,
par
exemple,
les
etudes
trans-
versales,
les
etudes
cas-temoins
ou
les
etudes
de
cohortes.
Au
total,
les
auteurs
ont
examine
46
ar-
ticles
qui
decrivaient
des
etudes
originales.
Extraction
de
donnees
On
a
cherche
des
renseignements
sur
l'association
(le
cas
echeant)
qu'il
y
avait
entre
le
chomage
et
le
bilan
de
sante,
par
exemple,
le
taux
de
mortalite,
des
causes
specifiques
de
d'ces,
I'apparition
de
troubles
physiques
et
mentaux
et
le
recours
a
des
services
de
soins
de
sante.
On
a
extrait
des
renseignements
sur
la
nature
de
l'association
(positive
ou
negative),
des
mesures
d'association
(risque
relatif,
ratio
de
probabilite
ou
ratio
de
mortalite
normalise)
et
la
tendance
de
la
causalite
('a
savoir
si
le
chomage
a
eu
des
consequences
negatives
sur
la
sante,
ou
vice
versa).
Synthese
des
donnees:
La
plupart
des
etudes
generales
ont
indique
qu'il
y
avait
une
association
posi-
tive
entre
le
taux
de
chomage
national
et
le
taux
de
mortalite
global
et
de
mortalite
imputables
'a
des
maladies
cardiovasculaires
et
des
suicides.
Cependant,
la
relation
entre
les
taux
de
chomage
et
les
taux
de
mortalite
par
accident
dautomobile
peut
etre
inverse.
Les
importantes
etudes
de
co-
hortes
fondees
sur
les
donnees
du
recensement
indiquent
des
taux
plus
eleves
de
mortalite
global,
de
deces
par
suite
de
maladie
cardiovasculaire
ou
de
suicide
chez
les
hommes
et
les
femmes
sans
travail
que
chez
les
autres
personnes
occupees
ou
la
population
en
general.
Les
travailleurs
mis
pied
ala
suite
d'une
fermeture
d'usine
ont
signale
un
plus
grand
nombre
de
symptomes
et
de
ma-
ladies
que
les
personnes
occupees;
on
a
pu
valider
objectivement
une
partie
de
ces
rapports.
Les
chomeurs
sont
sans
doute
plus susceptibles
que
les
personnes
occupees
de
consulter
leur
medecin,
de
prendre
des
medicaments
ou
d'etre
admis
a
un
hopital
general.
Une
association
possible
entre
le
chomage
et
le
taux
d'admission
'a
un
h6pital
psychiatrique
se
complique
par
d'autres
facteurs
insti-
tutionnels
et
environnementaux.
Conclusions:
ltvaluees
sur
une
base
6pidemiologique,
les
preuves
laissent
croire
qu'il
existe
une
forte
association
positive
entre
le
chomage
et
un
grand
nombre
de
r6sultats
defavorables
sur
le
plan
de
la
sante.
Reste
savoir
si
le
chomage
en
est
la
cause,
car
il
y
a
vraisemblablement
de
nombreux
fac-
teurs
mediateurs
et
confusionnels
qui
peuvent
etre
de
nature
sociale,
6conomique
ou
clinique.
Beaucoup
d'auteurs
ont
propose
des
m6canismes
de
causalit6,
mais
d'autres
recherches
s'imposent
pour
v6rifier
ces
hypothhses.
The
recent
recession
in
Canada
has
caused
a
high
level
of
unemployment.
According
to
Statistics
Canada,
in
March
1995,
10.8%
of
the
labour
force
was
unemployed.'
In
March
1993,
1
696
000
Canadians
(12.3%
of
the
labour
force)
were
out
of
work,
the
high-
est
level
since
World
War
11.2
This
official
figure,
how-
ever,
is
based
on
a
narrow
definition
of
"the
unem-
ployed":
those
people
who
actively
sought
work
in
the
preceding
4
weeks
and
who
did
not
work
more
than
1
hour
in
the
previous
week."
3
Excluded
are
two
large
groups
that
constitute
the
"hidden
unemployed."3
6The
first
group
consists
of
peo-
ple
on
the
"margins
of
the
labour
force":
those
"who
want
work
and
are
available
for
work"
but
did
not
seek
it
in
the
previous
week
because
of
illness,
personal
or
fam-
ily
responsibilities,
waiting
for
replies
to
job
applica-
tions,
or
having
given
up
looking
for
work
("discouraged
workers").24
The
second
group
comprises
those
who
hold
part-time
jobs
but
are
available
for
full-time
work
(the
"underemployed").2
Although
not
truly
jobless,
the
underemployed
may
be
said
to
suffer
relative
unemploy-
ment.
Including
these
two
groups
in
unemployment
fig-
ures
would
mean
a
"real"
unemployed
population
of
ap-
proximately
2
830
000
Canadians,
or
20.0%
of
the
labour
force,
in
March
1993
(the
last
year
in
which
data
were
collected
according
to
the
above
categories).2
Still
not
included
are
those
who
are
working
full-time
but
considered
overqualified
for
their
jobs,
also
sometimes
referred
to
as
"underemployed."
Whatever
the
"real"
rate,
unemployment
has
been
a
high-profile
issue,
yet
the
possible
adverse
impact
on
the
physical
and
mental
health
of
the
population
has
gener-
ally
received
little
attention
in
public
discourse
and
pol-
icy
making.7'8
In
the
health
and
social-science
literature,
however,
the
association
of
unemployment
(and
other
aspects
of
economic
hardship)
with
adverse
health
consequences
has
been
investigated
for
many
years.
In
1897
European
historian
Emile
Durkheim
observed
that
suicides
seemed
to
occur
more
often
during
economic
changes
that
dis-
turbed
the
"social
fabric"
of
society.9
Since
the
early
1970s,
many
studies
of
the
apparent
relation
between
indices
of
economic
downturn
and
overall
mortality
rates
in
Western
countries
have
been
published,
one
of
the
best-known
authors
being
M.
Har-
vey
Brenner
of
Johns
Hopkins
University.8'0,'
The
main
objective
of
this
article
is
to
review
the
epi-
demiologic
evidence
supporting
an
association
between
unemployment
and
health
outcomes
in
the
population.
Since
many
review
articles8',2"
and
commentaries22-28
have
already
been
published,
we
wished
not
only
to
in-
vestigate
any
association
but
also
to
test
the
evidence
ac-
530
CAN
MED
ASSOC
J
*
ler
SEPT.
1995;
153
(5)

cording
to
the
epidemiologic
criteria
for
causation
estab-
lished
by
Bradford
Hill.29
This
was
not
attempted
in
any
article
that
we
reviewed.
A
related
question
involves
the
direction
of
causation.
Does
unemployment
cause
poor
health,
or
is
it
more
likely
that
poor
health
causes
unem-
ployment?
The
latter
has
been
termed
the
"health-selec-
tion"
or
"reverse-causation"
hypothesis.`,`
DATA
SOURCES
We
searched
MEDLINE
with
the
use
of
the
MeSH
terms
"unemployment,"
"employment,"
"job
loss,"
"econ-
omy"
(or
"economic")
and
a
broad
range
of
health
out-
comes
(mortality,
morbidity
and
the
use
of
health
care
services)
for
articles
in
English.
A
secondary
search
was
conducted
of
references
in
the
articles
retrieved
through
the
MEDLINE
search.
To
ensure
that
the
review
was
current,
we
preferred
reports
of
original
research
pub-
lished
in
the
1980s
or
1990s;
however,
earlier
articles
considered
significant
were
also
included.
We
included
some
review
articles
and
commentaries
to
aid
in
finding
further
original
studies
and
to
provide
background
infor-
mation
on
the
issue
of
unemployment
and
health.
Cur-
rent
definitions
and
data
on
unemployment
were
ob-
tained
from
Statistics
Canada
publications.
We
reviewed
69
articles,
46
of
which
described
origi-
nal
research
studies.
We
categorized
these
studies
ac-
cording
to
their
design
and
level
of
data
collection
and
analysis.
In
terms
of
design,
studies
were
designated
cross-sectional
(studies
that
collected
and
analysed
data
at
one
point
in
time)
or
longitudinal
(those
that
analysed
data
collected
during
a
long
period,
often
years
or
decades).
In
terms
of
level,
we
considered
aggregate-level
or
macro-level
studies
in
which
data
for
the
entire
popula-
tion
of
nations,
states
or
cities
were
analysed.
Many
of
these
studies
used
time-series
analysis
to
examine
corre-
lations
between
unemployment
rates
and
health
status
indicators,
such
as
mortality
rates,
during
a
period
of
time.
By
contrast,
individual-level
or
micro-level
studies
measured
health
outcomes
among
a
sample
of
unem-
ployed
people
and
compared
these
outcomes
with
those
of
a
control
group
of
employed
people
or
with
those
of
the
general
population.
Individual-level
longitudinal
studies
involving
control
groups
had
cohort
or
case-
control
designs.
A
common
cohort-study
design
was
the
"factory-closure"
study,
in
which
the
health
outcomes
of
workers
laid
off
as
a
result
of
a
factory
closure
were
mea-
sured
prospectively
and
compared
with
those
of
workers
at
a
workplace
that
was
still
in
operation.
In
some
individual-level
studies,
relative
risks
were
calculated
as
the
ratio
of
the
incidence
of
a
health
out-
come
(usually
mortality
or
morbidity)
in
the
unem-
ployed
group
to
that
in
the
employed
group
or
in
the
general
population.
In
case-control
studies,
odds
ratios
were
calculated
to
estimate
the
relative
risks.
FINDINGS
The
studies
reviewed
are
categorized
according
to
their
main
health
outcome
measures:
mortality
rate
(overall
or
by
cause)
or
morbidity
rate,
including
use
of
health
care
services.
UNEMPLOYMENT
AND
OVERALL
MORTALITY
RATES
Among
the
aggregate-level
time-series
analyses
we
reviewed
were
several
by
Brenner
(with
Mooney
as
a
coauthor
on
some),
reporting
correlations
between
na-
tional
unemployment
levels
and
overall
mortality
rates
in
nine
Western
countries,
including
the
United
States
from
1909
to
1976
and
from
1940
to
1973,84114England
and
Wales
from
1936
to
1976,`2
Scotland
from
1952
to
1983,'5
and
Sweden
from
1940
to
1973.'7
In
1976
Bren-
ner
found
that
a
1%
rise
in
unemployment
was
corre-
lated
with
approximately
6000
excess
deaths
annually
in
the
United
States."
Gravelle,
Hutchinson
and
Stern32
criticized
Brenner's
time-series
analysis
for
omitting
20th-century
trends
in
income,
education,
occupation,
housing
status,
nutrition
and
medical
treatment.
Brenner
later
recognized
this
omission
and
constructed
more
sophisticated
models
that
took
these
other
factors
into
account.8'7
From
a
similar
time-series
analysis
for
Canada
from
1950
to
1977,
Adams33
found
a
generally
inverse
associa-
tion
between
annual
unemployment
levels
and
rates
of
overall
mortality.
Adams
gave
the
following
possible
rea-
sons
for
finding
an
inverse
relation:
(1)
faulty
assump-
tions
concerning
lag
times
between
increases
in
unem-
ployment
and
increases
in
mortality
rates,
(2)
"dilution"
of
the
association
between
joblessness
and
actual
finan-
cial
hardship
by
unemployment
insurance
benefits,
(3)
a
decrease
in
"societal
[business]
activity"
as
a
result
of
un-
employment,
and
therefore
lower
risks
of
work-related
deaths,
(4)
reduced
alcohol
and
tobacco
consumption
because
of
lack
of
employment
income,
and
therefore
lower
mortality
risks,
and
(5)
confounding
of
the
rela-
tion
between
unemployment
and
adverse
health
out-
comes
because
of
inequality
in
income.33
Adams
did
not
test
these
hypotheses.
In
individual-level
studies,
many
years
of
observation
are
needed
because
deaths
among
working-age
popula-
tions
are
relatively
infrequent.
Several
longitudinal
stud-
ies
conducted
in
Europe
achieved
adequate
statistical
power
by
identifying
large
cohorts
of
unemployed
peo-
ple
through
the
national
census.'v39
Table
1
gives
the
standardized
mortality
ratios
(SMRs)
or
relative
risks
(RRs)
of
mortality
estimated
for
these
cohorts
after
vary-
CAN
MED
ASSOC
J
*
SEPT.
1,
1995;
153
(5)
531
L-

ing
follow-up
periods.
Most
SMRs
were
considered
sta-
tistically
significant
(5%
probability
of
a
Type
I
error).
One
study
conducted
in
Britain
used
data
on
a
4%
random
sample
of
working-age
men
in
England
and
Wales
provided
by
the
Office
of
Population
Censuses
and
Surveys
(OPCS).3-36
The
men
were
defined
as
`un-
employed"
if
they
had
sought
work
in
the
week
before
the
census.
In
a
census-based
study
conducted
in
Italy,
the
cohort
was
defined
in
the
same
way.37
In
that
study,
men
defined
as
jobless
at
the
times
of
both
the
1976
and
1981
censuses
had
a
higher
SMR
than
those
out
of
work
in
1976
or
1981
only
(Table
1).
This
finding
suggests
that
longer-term
unemployment
is
more
harmful
than
short-term
joblessness.
A
Finnish
cohort
study
differed
from
these
studies
in
defining
"unemployed"
as
having
sought
work
at
any
time
in
the
year
before
the
census.38
A
striking
finding
of
this
study
was
that
the
SMR
increased
parallel
to
an
increasing
duration
of
unemployment
(from
1
to
12
months)
before
the
census
(Table
1).
A
census-based
study
in
Denmark
examined
unem-
ployed
female
as
well
as
male
workers.39
Workers
of
both
sexes
unemployed
in
1970
had
a
significantly
greater
SMR
than
their
employed
counterparts
during
the
sub-
sequent
10
years.
The
British
studies
based
on
OPCS
~
~
~ ~
JfL{
Y8
.~
..
.;
.,
-IA
l
(
|1iSrt'
t\,'r
t
;
VS>t,
-ftSJ-dl
iS
mDelfnitioinOf
~aAu.
-'
SaIdv
enwanhtin
unamnIWn~nt
Lused
data
also
found
higher
10-year
relative
mortality
rates
among
the
wives
of
men
who
were
unemployed
at
the
time
of
the
1971
census
(Table
1).35
The
similar
outcomes
of
these
large
cohort
studies
provide
evidence
of
a
positive
association
between
un-
employment
and
risk
of
death
from
all
causes.
Health
se-
lection
(reverse
causation)
was
only
a
minor
factor
be-
cause
the
studies
included
only
those
actively
seeking
work,
thus
excluding
people
who
are
chronically
ill
or
disabled.
The
editor
of
the
Britisb
Medical
Journal
com-
mented
in
1991
that
"the
evidence
that
unemployment
kills
-
particularly
the
middle-aged
-
now
verges
on
the
irrefutable.""
DEATH
DUE
TO
CARDIOVASCULAR
DISEASES
The
specific
causes
of
death
most
often
studied
were
cardiovascular
diseases
and
suicide.
Interest
in
outcomes
involving
cardiovascular
diseases,
especially
heart
dis-
ease,
arose
as
a
result
of
the
hypothesis
that
unemploy-
ment
induces
stress
and
may
therefore
be
a
risk
factor
for
heart
disease.,,,,'
Brenner
reported
positive
associations
between
unemployment
and
death
due
to
heart
disease
from
time-series
data
on
the
populations
of
the
United
States,
Canada,
Australia,
Denmark,
Finland,
France,
*s!
fi
/
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ite
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ASSOC
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Germany,
Sweden,8,6
England
and
Wales,'3,6
and
Scot-
land."5
These
associations
were
found
after
the
data
had
been
adjusted
for
trends
in
consumption
of
tobacco,
al-
cohol
and
dietary
fat
16,17
and,
in
Scotland,
for
increased
death
rates
during
unusually
long,
cold
winters.'5
Bunn42
reported
positive
correlations
between
unem-
ployment
and
death
due
to
heart
disease
from
the
results
of
an
aggregate-level
study
in
Australia.
Adams'
analysis
of
Canadian
data
also
revealed
that
unemployment
had
a
positive
relation
with
rates
of
death
due
to
heart
disease,
despite
the
inverse
correlation
with
overall
mortality
rates.33
To
account
for
these
contrary
findings,
Adams
postulated
that
fatal
heart
disease
occurs
mainly
in
older
adults,
but
that
their
jobless
rate
runs
counter
to
the
overall
trend:
a
general
job
scarcity
encourages
older
workers
to
retire
from
the
labour
force,
hence
lowering
their
unemployment
rate.33
The
results
of
census-based
longitudinal
studies
con-
ducted
in
Europe
on
cardiovascular
causes
of
death
and
their
relation
to
unemployment
are
summarized
in
Table
2.
Significantly
higher
SMRs
for
these
causes
of
death
were
found
among
the
British
cohort
of
unemployed
men
from
the
1981
census,
the
wives
of
the
men
(al-
though
not
the
men
themselves)
in
the
1971
cohort,
the
Finnish
cohort
of
men
in
the
1980
census
and
the
Dan-
ish
cohorts
of
men
and
women
in
the
1970
census.34363839
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Significantly
high
SMRs
for
death
due
to
ischemic
heart
disease
were
found
in
the
British
cohort
of
men
in
the
1981
census36
and
for
deaths
from
myocardial
infarction
in
the
Finnish
cohort.38
Rates
of
death
due
to
stroke
have
also
been
examined.
Franks
and
associates43
analysed
data
provided
by
the
OPCS
on
adults
45
to
74
years
of
age
living
in
Greater
London
from
1971
to
1981.
They
found
a
strong
correla-
tion
between
rates
of
death
due
to
stroke
and
unemploy-
ment
among
men,
imputing
a
"dose-response"
relation
of
5.4
excess
deaths
due
to
stroke
per
100
000
men
for
every
1
%
increase
in
the
jobless
rate.
However,
no
significant
association
was
found
among
women.43
Brenner
and
Mooney8
also
reported
positive associations
between
un-
employment
rates
and
rates
of
mortality
due
to
cerebrovas-
cular
causes
in
Canada,
Sweden,
France
and
Germany.
Some
individual-level
studies
looked
at
intermediate
cardiovascular
outcomes
such
as
elevated
levels
of
blood
pressure
or
serum
cholesterol.
9404'
44
In
a
retrospective
cohort
study
of
Swedish
male
shipyard
workers
threat-
ened
with
job
loss,
the
subjects
had
increases
in
mean
serum
cholesterol
and
triglyceride
levels
as
well
as
sys-
tolic
and
diastolic
blood
pressure;
they
also
gained
weight."
Sleep
disturbance,
experienced
by
many
of
the
workers,
was
thought
to
be
a
sign
of
stress.
The
large
sample
size
of
this
study,
and
the
fact
that
the
investiga-
tors
controlled
for
potentially
confounding
factors
af-
fecting
cardiovascular
risk
(dietary,
tobacco
and
alcohol
intake),
strengthened
the
findings.44
SUICIDE
Platt2O
reviewed
95
studies
of
unemployment
or
job
loss
and
suicide
or
attempted
suicide
published
from
1953
to
1982.
Most
individual-level,
cross-sectional
studies
reviewed
found
that
people
who
committed
sui-
cide
were
more
likely
to
be
jobless
when
they
died
than
were
people
who
died
from
other
causes.
However,
it
was
difficult
to
show
that
job
loss
had
triggered
individ-
ual
acts
of
suicide.20
Aggregate-level
cross-sectional
studies
conducted
in
the
United
States,
England
and
Europe
did
not
consis-
tently
show
a
higher
incidence
of
reported
suicide
in
ar-
eas
of
high
unemployment.
In
fact,
they
found
that,
in
areas
of
low
unemployment,
jobless
people
may
actually
have
reacted
worse
than
those
in
areas
where
many
oth-
ers
were
also
out
of
work.20
In
aggregate-level,
longitudinal
studies,
Brenner
and
Mooney8
found
that
unemployment
was
positively
cor-
related
with
suicide
rates
in
several
Western
countries.
Individual-level
longitudinal
studies
provided
even
stronger
evidence
of
an
association.
Most
case-control
analyses
found
significantly
greater
"unemployment,
job
instability
or
occupational
problems"
among
people
who
had
committed
or
attempted
suicide
than
among
those
who
had
not.9'20
Among
the
census-based
cohorts
of
un-
employed
British
men,34
Finnish
men,38
and
Danish
men
and
women,39
rates
of
death
due
to
suicide
were
1.6,
1.9
and
2.5
times
greater,
respectively,
than
those
of
the
ref-
erence
populations
(Table
2).
Two
recent
time-series
analyses
found
strong
aggre-
gate-level
correlations
between
unemployment
and
sui-
cide
among
young
adults,
especially
men.
Morrell
and
collaborators45
found
the
same
pattern
over
an
83-year
period
from
1907
to
1990
in
Australia.
Other
analyses
have
found
strong
correlations
between
unemployment
and
suicide
among
young
men
in
France,
Australia,
the
United
States
and
Canada
between
1966
and
1987,
but
weak
correlations
in
Sweden,
Japan
and
the
former
West
Germany
during
the
same
period.4
These
last
three
countries
have
historically
had
low
rates
of
youth
unem-
ployment;
as
well,
unemployed
people
have
had
strong
support
from
state
welfare
in
Sweden
and
the
former
West
Germany,
and
from
family
networks
in
Japan.45-
Pritchard46
also
noted
significant
correlations
between
unemployment
and
suicide
rates
in
young
men
in
9
of
12
European
countries
between
1974
and
1987.
Health
selection
may
be
an
important
confounding
factor
affecting
the
results
of
such
studies;
psychiatric
ill-
ness
can
predispose
people
both
to
unemployment
and
to
suicide.
Conversely,
the
association
with
unemploy-
ment
may
be
underestimated
as
a
result
of
the
known
under-reporting
of
suicide
and
the
misreporting
of
sui-
cide
as
accidental
death.
Cultural
attitudes
toward
sui-
cide
and
the
availability
of
firearms
further
complicate
the
picture.33
Still,
"economic
insecurity"
(such
as
that
caused
by
unemployment)
may
be
an
"important
an-
tecedent
variable
in
the
causal
chain"
leading
a
person
to
harm
himself
or
herself.
8,20
DEATHS
DUE
TO
MOTOR-VEHICLE
ACCIDENTS
Adams33
found
an
inverse
correlation
between
unem-
ployment
levels
and
rates
of
fatalities
in
motor-vehicle
accidents
in
Canada.
When
unemployment
is
high,
there
may
be
a
decline
in
business-related
traffic;
people
may
be
less
able
to
afford
to
drive
and
therefore
less
ex-
posed
to
the
risk
of
traffic
accidents.33
A
time-series
analysis
from
1976
to
1980
in
the
United
States
also
found
this
negative
association,
espe-
cially
among
young
men.47
The
national
rate
of
traffic
fa-
talities,
traditionally
the
highest
in
this
demographic
group,
seemed
to
fall
when
the
unemployment
level
rose.
However,
when
the
researchers
controlled
for
the
num-
ber
of
miles
driven,
unemployment
was
associated
with
higher
rates
of
traffic
fatalities.
The
authors
suggested
that
the
stress
of
joblessness
may
cause
poorer
attention
to
safe
driving,
but
they
did
not
test
this
hypothesis.
534
CAN
MED
ASSOC
J
*
ler
SEPT.
1995;
153
(5)
-

PHYSICAL
AND
MENTAL
DISORDERS
D'Arcy
and
Siddique3'48
analysed
the
results
of
the
1978-79
Canada
Health
Survey
to
find
the
relation
of
unemployment
to
physical
or
psychologic
health
out-
comes.
In
comparison
with
employed
people,
unem-
ployed
people
had
greater
self-reported
levels
of
"psy-
chological
distress,"
"anxiety
or
depressive
symptoms,"
"current
health
problems,"
"short-term
disability"
(caus-
ing
absence
from
work
for
the
previous
2
weeks),
"long-
term
disability"
(absence
from
work
for
the
previous
12
months),
hospital
admissions
in
the
past
year
(2.1
times
more
than
employed
people)
and
visits
and
telephone
calls
to
physicians
(33%
more
than
employed
people).
Differences
remained
significant
after
adjustment
for
de-
mographic
and
socioeconomic
factors.
The
analysis
of
the
Canada
Health
Survey
had
limita-
tions.
Because
it
was
cross-sectional,
it
could
not
suggest
the
direction
of
causation.
Health
selection
could
not
be
ruled
out
since
respondents
who
were
already
ill
could
have
been
clustered
among
the
unemployed
people
sur-
veyed.
As
well,
some
difference
found
to
be
statistically
significant
as
a
result
of
the
large
sample
size
were
of
ques-
tionable
health
significance;
for
example,
unemployed
people
reported
a
mean
1.14
"current
health
problems"
whereas
a
mean
1.02
were
reported
by
employed
people.
We
reviewed
two
Canadian
and
two
European
indi-
vidual-level
"factory-closure"
studies.
In
Canada,
Grayson30
followed
a
cohort
of
310
men
laid
off
when
a
ball
bearings
manufacturer
shut
down
during
the
1981-82
recession.
Those
still
jobless
after
2
years
reported
greater
stress,
poorer
overall
health,
more
visits
to
physicians
and
more
medications
taken
than
when
they
were
working.
Their
spouses
also
reported
more
symptoms
after
the
layoffs.
However,
this
study
had
a
"before-after"
design
and
lacked
a
control
group
of
workers.
Moreover,
those
workers
still
unemployed
after
2
years
may
have
been
in
poorer
health
than
others
be-
fore
the
plant
closure;
their
prolonged
unemployment
may
have
been
due
to
the
health-selection
effect.
Grayson
also
studied
the
effect
of
the
closure
of
the
Toronto
plant
of
Canadian
General
Electric
in
1984.49
The
400
laid-off
workers
were
mainly
male,
highly
skilled
and
well
paid;
they
had
worked
at
the
plant
a
mean
of
14
years.
Up
to
27
months
after
the
plant
clo-
sure,
half
of
the
workers
and
their
spouses
"still
ranked
the
stress
as
greater
than
or
equal
to
divorce."
In
compar-
ison
with
the
Ontario
respondents
to
the
Canada
Health
Survey,
the
laid-off
workers
and
their
spouses
reported
more
"headaches,"
"hay
fever
or
allergy,"
"back,
limb
or
joint
disorders"
and
"arthritis."
However,
the
clinical
sig-
nificance
of
these
symptoms
was
not
explored,
nor
were
the
symptoms
confirmed
by
medical
examination.
Grayson
mentioned
"abnormal
illness
behaviour`
as
an
explanation
for
the
higher
rate
of
symptoms,
although
he
believed
the
workers'
suffering
to
be
genuine.
Iversen,
Sabroe
and
Damsgaard5o
tested
1000
laid-off
Danish
shipyard
workers
for
psychiatric
symptoms
dur-
ing
a
3-year
follow-up
period
and
found
significantly
worse
results
among
the
sample
than
among
a
control
group
of
workers
employed
at
another
shipyard.
This
study
had
several
strengths:
a
large
sample
size,
a
do
matched
control
group,
adequate
follow-up
and
a
vali-
dated
instrriment
for
measuring
mental
health.
In
a
sm.riier
cohort
study
of
85
workers
laid
off
as
a
result
of
the
closure
of
a
Norwegian
sardine
factory,
Westin,
Norum
and
Schlesselman5'
found
that,
during
the
4
years
after
plant
closure,
rates
of
sick
leave
and
dis-
ability
pensions
collected
(proxy
indicators
of
morbid-
ity)
were
two
and
three
times
greater,
respectively,
among
the
laid-off
workers
than
those
among
a
control
group
of
workers."'
However,
this
study
did
not
control
for
any
nonmedical
incentives
for
taking
sick
leave
or
collecting
pensions.
Dooley
and
Catalano52
combined
aggregate-level
and
individual-level
analysis
in
a
study
with
cross-level
de-
sign
to
examine
the
relations
among
individual
job
loss,
the
unemployment
rate
and
mental
health
outcomes.
They
surveyed
8000
people
in
Greater
Los
Angeles
with
the
use
of
random
interviews
by
telephone
from
1978
to
1982.
Results
showed
that
individual
job
loss
explained
more
of
the
variance
in
mental
health
outcomes
than
did
the
regional
unemployment
rate,
which
ranged
from
4.8%
to
8.6%.
Moreover,
job
loss
occurred
significantly
more
frequently
among
people
with
a
lower
socioeco-
nomic
status,
defined
by
income
and
education,
than
among
those
with
an
upper
or
middle
socioeconomic
status.
Thus,
social
class
had
a
greater
influence
than
the
prevailing
economic
climate
(as
reflected
by
the
unem-
ployment
rate)
on
mental
health
outcomes.
ALCOHOL
CONSUMPTION
In
the
analysis
of
data
from
the
Canada
Health
Sur-
vey,
unemployed
respondents
reported
a
lower
mean
al-
cohol
intake
than
employed
respondents.48
Two
other
Canadian
cross-sectional
studies
found
more
drinking
among
unemployed
than
among
employed
people;
how-
ever,
these
studies
included
heavy
drinkers
who
were
jobless
because
of
their
drinking.53
54
A
recent
prospective
study
of
1000
young
adults
in
Sweden
found
a
"clear
[positive]
correlation"
between
heavier
drinking
and
job-
lessness,
especially
long-term
joblessness;
the
correlation
was
stronger
for
young
men
than
for
young
women.55
In
contrast,
a
recent
British
cohort
study
did
not
find
that
alcohol
intake
increased
with
"nonemployment";
how-
ever,
this
study
involved
retirees
as
well
as
those
who
had
lost
their
jobs.56
CAN
MED
ASSOC
J
*
SEPT.
1,
1995;
153
(5)
535

Therefore,
depending
on
the
circumstances,
unem-
ployment
may
be
associated
with
decreased
alcohol
con-
sumption
due
to
lack
of
money
or
with
increased
intake
because
of
more
leisure
time
or
a
poor
coping
response.
USE
OF
MENTAL
HEALTH
SERVICES
Because
data
in
the
area
are
routinely
collected
and
made
available,
use
of
health
care
services
was
often
cho-
sen
as
the
outcome
in
studies
of
unemployment
-and
health.
Measures
of
service
use
do
not
reflect
actual
dis-
ease
incidence
as
much
as
the
burden
of
illness
on
societal
resources;
hence,
results
using
these
measures
have
policy
implications.
We
reviewed
three
Canadian
and
three
US
analyses
of
the
use
of
mental
health
care
services.
Adams'
time-series
analysis
for
Canada
found
a
posi-
tive
correlation
between
unemployment
levels
and
rates
of
admission
to
psychiatric
hospitals
for
"psychotic"
di-
agnoses.33
However,
Trainor,
Boydell
and
Tibshiranill
found
an
inverse
association
between
unemployment
and
rates
of
admission
to
and
discharge
from
psychiatric
hospitals
in
Metropolitan
Toronto
from
1978
to
1983.
Other
factors
influencing
admission
and
discharge
rates
were
changes
in
admission
criteria
and
hospital
capacity
levels.
In
a
study
of
admissions
to
and
discharges
from
Hamilton
Psychiatric
Hospital,
Hamilton,
Ont.,
from
1960
to
1977,
Dear,
Clark
and
Clark58
found
that
the
economic
climate
may
have
indirectly
affected
rates
by
influencing
changes
in
hospital
policy.
The
trend
toward
moving
psychiatric
patients
from
institutional
to
commu-
nity
care
during
this
period
was
likely
also
a
major
factor.
Brenner
and
Mooney"'.'
reported
positive
correlations
between
unemployment
and
first-time
admissions
to
psy-
chiatric
hospitals
in
New
York
state
during
a
50-year
pe-
riod
up
to
1967
on
the
basis
of
time-series
data.
Ahr,
Gorodezky
and
Cho,59
in
a
study
conducted
in
Missouri
in
the
1970s,
found
that
unemployment
was
correlated
with
readmissions,
but
not
first-time
admissions,
to
state
psychi-
atric
hospitals.
In
a
before-after
comparison,
readmissions
increased
by
30%
and
outpatient
caseloads
by
more
than
50%
in
the
6
months
after
the
jobless
rate
had
peaked.
Kiernan
and
colleagues,'
in
a
study
conducted
in
Illi-
nois
between
1970
and
1985,
found
a
bimodal
(two-
peak)
lagged
effect
of
"decreased
labour
force
participa-
tion."
After
1
month,
they
found
increased
admissions
to
psychiatric
hospitals,
probably
involving
people
with
marginal
mental
health
who
were
"tipped
over
the
edge"
by
hard
times.
They
also
saw
a
more
gradual
(3-
to 6-
month)
lagged
increase
in
community-agency
caseloads,
which
may
have
been
made
up
of
more
stable
people
who
had
exhausted
their
personal
resources.,"
An
individual-level
retrospective
cohort
study
by
Linn,
Sandifer
and
Stein6
documented
more
frequent
somatization,
depression,
anxiety,
physician
visits
and
medication
use
among
unemployed
US
military
veterans
than
among
employed
veterans.
However,
this
study
had
a
small
sample
(30
subjects
and
30
controls).
USE
OF
GENERAL
HEALTH
CARE
SERVICES
Several
studies
reported
increased
use
of
general
health
care
services,
evinced
by
increases
in
such
measures
as
vis-
its
to
physicians,
hospital
inpatient
or
outpatient
admis-
sions
and
use
of
prescription
medication6244'61-64
(Table
3).
In
D'Arcy
and
Siddique's
analysis,3'48
one
in
six
unem-
ployed
people
reported
admission
to
hospital
in
the
previ-
ous
year,
compared
with
one
in
13
employed
respondents.
Unemployed
respondents
also
reported
33%
more
visits
to
physicians:
a
mean
of
3.40
visits
in
the
previous
year,
compared
with
2.55
by
employed
respondents.
Long-term
follow-up
studies
of
British
workers
laid
off
as
a
result
of
factory
closure62.3
found
that
these
workers
had
double
the
rate
of
general
hospital
admis-
sions,
60%
to
63%
more
outpatient
visits
and
20%
to
57%
more
visits
to
general
practitioners
than
all
work-
ing-age
men.
Linn
and
coworkers"'
found
that,
at
any
one
time,
unemployed
US
veterans
were
taking
a
mean
3.6
medications,
compared
with
1.9
medications
being
taken
by
employed
veterans
(Table
3).
Yuen
and
Balarajan's
longitudinal
study64
of
13
275
unemployed
men
found
significantly
higher
odds
that
these
men
had
consulted
general
practitioners
in
the
past
week
than
had
the
reference
group
of
all
working-age
men
(odds
ratio
[OR]
1.83).
For
those
jobless
for
5
or
more
years,
the
odds
were
even
greater
(OR
2.12).
Ex-
clusion
of
those
with
chronic
illnesses
from
the
analysis
(to
minimize
health-selection
bias)
still
resulted
in
a
sig-
nificant
OR
of
1.53
(Table
3).
The
association
of
unemployment
with
increased
use
of
health
care
depends,
however,
on
the
services
being
universally
available
and
free
of
charge
at
point
of
use,
as
they
are
in
Canada
and
Britain
and
for
military
veterans
in
the
United
States.t0266261
In
the
United
States,
in
con-
trast,
hard
economic
times
may
mean
"nearly
empty
waiting
rooms"
because
jobless
people
often
lack
health
insurance
and
the
ability
to
pay.
This
has
been
called
the
inverse-care
law":
those
most
in
need
of
care
become
the
least
likely
to
receive
it.27
DISCUSSION
WEIGHING
THE
EVIDENCE:
CRITERIA
FOR
CAUSATION
We
assessed
the
study
findings
from
this
literature
review
according
to
the
epidemiologic
criteria
for
cau-
sation.29
Because
we
reviewed
only
published
docu-
536
CAN
MED
ASSOC
J
*
ler
SEPT.
1995;
153
(5)

ments,
our
assessment
may
be
vulnerable
to
publication
bias
(the
tendency
for
positive
study
findings
to
be
published
and
cited
more
often
than
negative
or
neu-
tral
results).
Temporal
direction
dinal
studies
such
as
those
of
European
census-based
co-
horts
and
of
factory
closures.
Significant
adverse
health
events
followed
job
loss;
the
reverse
temporal
direction
was
not
found.
30343949-5
Strength
of
association
Most
aggregate-level
time-series
analyses
demon-
strated
increased
rates
of
adverse
health
outcomes
fol-
lowing
rises
in
unemployment.8
0720424352
The
time
lags
varied
among
studies,
however;
among
Brenner's
studies,
the
reported
lags
ranged
from
2
to
10
years.8'21'5-'7
Time
lags
remain
an
issue
of
some
contention.65
Stronger
evidence
came
from
individual-level
longitu-
Only
individual-level,
not
aggregate-level,
studies
could
be
assessed
by
this
criterion
on
the
basis
of
the
RRs,
ORs
and
SMRs
reported
for
people
"exposed"
to
unemployment
compared
with
those
not
exposed.
All
of
the
published
RRs
and
ORs
exceeded
1.0,
and
all
SMRs
exceeded
100;
most,
although
not
all,
reported
associa-
tions
were
statistically
significant.
Most
RRs
and
ORs
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were
in
the
range
of
1.2
to
2.0
and
SMRs
from
120
to
200,
3396163,4
a
magnitude
considered
moderate.
Dose-response
relation
In
the
Finnish
census-based
cohort
study,
subgroups
of
men
who
were
jobless
for
long
periods
had
progres-
sively
higher
SMRs
the
longer
they
were
unemployed
(Table
t
).38
In
the
study
conducted
in
Greater
London,
Franks
and
associates43
found
that
the
rate
of
death
due
to
stroke
among
men
increased
by
5.4
per
100
000
for
every
1%
rise
in
the
unemployment
rate.
The
evidence
from
these
two
studies
is
only
suggestive;
most
studies
did
not
address
the
dose-response
relation.
Consistency
of
findings
A
positive
association
was
found
consistently
in
ag-
gregate-level
studies
of
rates
of
overall
mortality
(the
study
by
Adams
being
an
exception"3)
and
of
death
due
to
cardiovascular
disease.
81017,20,33,42,45,46
Adams'
Canadian
time-series
analysis"3
suggested
an
inverse
relation
be-
tween
unemployment
and
deaths
due
to
motor-vehicle
accidents,
but
the
US
time-series
analysis47
found
a
mixed
association.
Individual-level
longitudinal
studies
consistently
showed
an
association
with
increased
suicide
rates
20,34,38,39
with
general
physical
or
mental
health
prob-
lems
30,31,44,4-48,50,52,62
and
with
greater
use
of
general
health
care
services.3'4864
However,
findings
concerning
the
use
of
mental
health
services
(especially
psychiatric-
hospital
admissions)57-60
and
alcohol
consumption
were
inconsistent."-56
Experimental
evidence
There
were
no
experiments
(such
as
randomized
con-
trolled
trials)
involving
the
deliberate
exposure
of
people
to
job
loss,
for
obvious
ethical
reasons.
Specificity
The
association
between
unemployment
and
poor
health
lacked
specificity:
no
particular
physical
or
men-
tal
health
problem
was
caused
only
by
the
lack
of
a
job;
conversely,
unemployment
did
not
cause
just
one
kind
of
disorder.
The
range
of
health
effects
appeared
to
be
very
broad
in
all
of
the
studies.
Analogy
Although
the
studies
reviewed
did
not
test
this
crite-
rion
directly,
we
inferred
that
the
unemployment-ill
health
association
is
analogous
to
the
reported
associa-
tions
between
other
negative
social
or
economic
condi-
tions
(such
as
poverty,
low
educational
levels
or
inequal-
ity
among
social
classes)
and
adverse
health
outcomes.
These
associations
have
been
reported
by
many
authors;`'
review
of
the
numerous
studies
is
beyond
the
scope
of
this
article.
Biologic
plausibility
Unemployment
may
exert
detrimental
effects
on
health
through
many
mechanisms:
(1)
by
disrupting
community
and
personal
social
relationships,6
8
928
4l
69
(2)
by
leading
to
greater
risk
behaviour
(alcohol
con-
sumption
and
poor
diet),8254445
(3)
by
causing
stress,283646
and
(4)
by
precipitating
a
bereavement
reaction,
like
that
caused
by
other
losses.628
These
mechanisms
lend
plausibility
to
the
hypothesis
that
unemployment
causes
mental
or
physical
health
problems;
this
connection,
in
turn,
may
make
the
ob-
served
association
with
increased
mortality
rates
plausible.
We
did
not
assess
the
evidence
for
any
particular
mechanism
or
series
of
mechanisms
since
our
main
pur-
pose
was
to
assess
whether,
not
how,
unemployment
has
adverse
effects
on
health.
However,
our
review
found
much
postulation
and
discussion
of
mechanisms
without
any
actual
testing
of
specific
hypotheses.
Further
re-
search
is
needed
to
untangle
the
complex
web
of
causa-
tion,
which
involves
many
factors
that
initiate,
mediate
and
prolong
health
problems.
CONCLUSION
In
keeping
with
the
common
perception
that
unem-
ployment
is
an
adverse
life
event
or
condition,
we
found
that
the
evidence
strongly
supports
an
association
be-
tween
unemployment
and
a
greater
risk
of
morbidity
(physical
or
mental
illness
or
use
of
health
care
services),
both
at
the
population
and
individual
levels,
and
a
greater
risk
of
mortality
at
the
population
level.
Epidemiologic
evidence
suggests
that
the
direction
of
causation
from
unemployment
to
illness
is
greater
than
the
converse
(illness
causes
unemployment);
however,
the
relation
is,
as
mentioned
above,
complex.
Although
more
research
can
be
done
to
elucidate
mechanisms
and
mediating
factors,
there
is
enough
evi-
dence
to
recommend
that
intervention
research,
to
de-
termine
ways
to
reduce
the
adverse
effect
of
unemploy-
ment
on
health,
be
a
priority.
Primary
prevention
strategies,
involving
the
prevention
or
reduction
of
un-
employment,
should
be
tested,
as
well
as
secondary
and
tertiary
prevention
of
recurrent
or
permanent
adverse
health
consequences
of
unemployment.
Although
unemployment
and
economic
issues
may
seem
beyond
the
usual
bounds
of
health
care,
physicians
538
CAN
MED
ASSOC
J
*
ler
SEPT.
1995;
153
(5)

and
other
health
care
professionals
have
the
opportunity
to
recognize,
treat
and
possibly
prevent
the
adverse
con-
sequences
of
unemployment
for
their
patients.
Beyond
caring
for
individuals,
however,
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also
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an
important
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in
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*
ler
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1995;
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For
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