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Australian & New Zealand Journal of Psychiatry
2014, Vol. 48(4) 333 –340
DOI: 10.1177/0004867414521502
© The Royal Australian and
New Zealand College of Psychiatrists 2014
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Australian & New Zealand Journal of Psychiatry, 48(4)
The effects of involuntary job loss on
suicide and suicide attempts among
young adults: Evidence from a matched
case–control study
Allison Milner1, Andrew Page2, Stephen Morrell3, Coletta Hobbs4,
Greg Carter5, Michael Dudley6, Johan Duflou7 and
Richard Taylor8
Abstract
Objective: To assess the influence of involuntary job loss on suicide and attempted suicide in young adults.
Method: A population-based case–control study of young adults (18–34 years) was conducted in New South Wales,
Australia. Cases included both suicides (n=84) and attempts (n=101). A structured interview was conducted with next of
kin (for suicide cases) and suicide attempters admitted to hospital. Controls selected from the general population were
matched to cases by age and sex. Job dismissal or redundancy (involuntary job loss) in the 12 months before suicide
or attempt was the main study variable of interest. Suicide and attempts were modelled separately and in combination
as outcomes using conditional logistic regression modelling. The analysis was also adjusted for marital status, socio-
economic status and diagnosis of an affective or anxiety disorder.
Results: Following adjustment for other variables, involuntary job loss was associated with an odds ratio of 1.82 for
suicide and attempted suicide (combined) (95% CI 0.98 to 3.37; p=0.058). Low socio-economic status was associated
with an odds ratio of 3.80 for suicide and attempted suicide (95% CI 2.16 to 6.67; p<0.001) compared to high socio-
economic status (after adjustment). Diagnosis of a mental disorder was associated with a 7.87 (95% CI 5.16 to 12.01;
p<0.001) odds ratio of suicide and attempted suicide compared to no diagnosis (after adjustment). Involuntary job loss
was associated with increased odds of suicide and attempts when these were modelled separately, but results did not
reach statistical significance.
Conclusions: Involuntary job loss was associated with increased odds of suicide and attempted suicide. The strength of
this relationship was attenuated after adjustment for socio-economic status and mental disorders, which indicates that
these may have a stronger influence on suicide than job loss.
Keywords
Depression, job loss, mental disorder, redundancy, suicide, unemployment
1
McCaughey VicHealth Centre for Community Wellbeing, Melbourne School of Population and Global Health, University of Melbourne, Melbourne,
Australia
2School of Science and Health, University of Western Sydney, Campbelltown, Australia
3School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia
4Sydney School of Public Health, University of Sydney, Sydney, Australia
5Centre for Translational Neuroscience and Mental Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
6School of Psychiatry, University of New South Wales, Sydney, Australia
7Sydney Medical School, University of Sydney, Sydney, Australia
8Faculty of Medicine, University of New South Wales, Sydney, Australia
Corresponding author:
Richard Taylor, School of Public Health and Community Medicine (SPHCM), Faculty of Medicine, University of New South Wales (UNSW),
Kensington (Main) Campus, Samuels Building, Level 2, Room 223, Botany St, Gate 11, Randwick, NSW 2052, Australia.
Email: r.taylor@unsw.edu.au
521502ANP0010.1177/0004867414521502Australian & New Zealand Journal of PsychiatryMilner et al.
research-article2014
Research
334 ANZJP Articles
Australian & New Zealand Journal of Psychiatry, 48(4)
Background
Involuntary job loss occurs when an individual loses a job
due to workplace closure, being fired or being made redun-
dant (Schröder, 2012). This represents an acutely stressful
event in a person’s life and is a different construct from
unemployment, which incorporates the process of looking
for work (Berchick et al., 2012; Burgard et al., 2007). There
is some evidence from longitudinal studies that involuntary
job loss is associated with a greater likelihood of depressive
symptoms (Berchick et al., 2012; Burgard et al., 2007;
Schröder, 2012), although no studies focusing on the rela-
tionship between involuntary job loss and mental health
have been conducted in Australia.
Most past studies on suicide have focused on unemploy-
ment rather than involuntary job loss (Blakely et al., 2003;
Morrell et al., 1993, 1998, 2001, 2007). Among the small
number of existing studies on involuntary job loss and sui-
cide, two were ecological analyses and therefore may not
provide evidence about the relationship between job loss
and suicide at the individual level (Classen and Dunn,
2012; Eliason and Storrie, 2009). The remaining study was
based on a specific occupational group (two meat process-
ing plants in the Hawkes Bay region of New Zealand)
(Keefe et al., 2002). All these studies found that involuntary
job loss was a significant risk factor for suicide.
The present study examines the relationship of invol-
untary job loss to suicide and attempted suicide using a
population-based case–control study of young adults
(18–34 years) in New South Wales (NSW), Australia.
Young adults in Australia have been identified as being
at higher risk of suicide attempt, self-harm (Martin et al.,
2010) and mortality, including suicide (Australian
Bureau of Statistics, 2012), than older age groups. Young
adults also have the highest rates of unemployment and
under-employment in the working-age population
(Australian Bureau of Statistics, 2009; Page et al., 2013).
The present study focuses on the potential risks associ-
ated with the effects of involuntary job loss, as distinct
from investigating the category of unemployment. A
strength of the data used in this paper is the sample size,
which is comparatively larger than those reported in
other studies for this age group (Beautrais et al., 1997;
Brent et al., 1993; Charlton, 1995; Lesage et al., 1994)
and is also based on matched population-based cases and
controls.
Methods
Study design
A population-based case–control study design was used to
investigate suicide deaths and suicide attempts in young
adults aged between 18 and 34 years in NSW, Australia
covering both metropolitan and rural areas.
Case selection
Information on coronial-determined suicides was obtained
from The National Coronial Information System (NCIS)
and covered a large proportion of NSW, which included the
Coronial Court jurisdictions of Sydney, Westmead,
Wollongong, Newcastle, Maitland, East Maitland, Bathurst,
Orange and Dubbo for the period 2003–2008. We selected
these areas a priori to cover both metropolitan and rural
areas of the state in order to capture geographical differ-
ences in both suicide and job loss.
A coronial file audit was then conducted by the research
team for each case to enumerate contact details for the next
of kin or significant other. All files on coroner-determined
suicides were examined to obtain contact details for the
next of kin or significant others (n=219) in consultation
with forensic counselling. Of the 219 suicides in the coro-
nial data originally extracted by the authors, 120 cases with
available contact information for next of kin were identi-
fied after exclusions and deemed suitable for contact by
forensic counsellors. An invitation to participate in the
research was sent by mail on behalf of the Chief Forensic
Pathologist of NSW.
The participation rate was 70% (n=84) of the 120 next of
kin contacted. The next of kin took part in face-to-face
interviews to complete a questionnaire about socio-demo-
graphic factors, life events and other antecedent circum-
stances of the suicide case. Interviews took place at a time
and place convenient for the interviewee either in person
(face-to-face) or by phone. One next-of-kin interview was
conducted for each suicide case.
Attempted suicide case recruitment occurred when
patients were admitted to hospital following a suicide
attempt. Patients were recruited at the Mater Hospital in
Newcastle and at the Prince of Wales and Sutherland
Hospitals in Sydney. All patients in the 18–34 age range
admitted to hospital following a suicide attempt were
approached by a clinician to ascertain their interest in
research participation. Interested patients were then asked
if they were willing to receive information about research
participation in the study by mail. Prospective participants
were subsequently contacted by the research team to
arrange an interview. An invitation to participate in the
research was sent to 343 potential participants. Contact to
confirm interviews was made with 214 young adults and
interviews were conducted with 47% (n=101).
Control selection
The sampling frame for population-based controls was pro-
vided by the Australian Bureau of Statistics (ABS) and
derived from the Census of Population and Housing and the
Monthly Population Survey (MPS) design framework.
Census Collection Districts (CDs) were selected systemati-
cally according to the Socio-Economic Indexes for Areas
Milner et al. 335
Australian & New Zealand Journal of Psychiatry, 48(4)
(SEIFA) and corresponded to the Local Government Area
(LGA) characteristics covered by the coronial and hospital
jurisdictions described above. CDs were selected such that
there was an 80% probability that the residences contained
young adults for strata matching to the sex and age group
(within 2–3 years) of the cases.
Controls (n=250) were those aged 18–34 years and who
resided in the regions from which suicide cases were drawn.
Of the 1439 households approached, 304 relatives or
friends were nominated, from which a total of 250 inter-
views were conducted (response 82%). More controls than
cases were recruited (3:1 control-to-case ratio) to maximise
statistical power given the small number of cases in the
geographic catchments accruable over the study period.
Suicide controls were asked to nominate an informant (par-
ent, relative or friend), and the informant completed the
same interview as completed by the next of kin of suicide
cases. As in the cases, the interview for suicide controls was
conducted face-to-face and related to socio-demographic
factors, life events and other suicide risk factors, eliminat-
ing the potential for differential recall bias emanating from
differing interview modes between case and control
respondents.
Post hoc analysis of recruited controls for metropolitan
Sydney and Hunter Region catchments showed similar sex
and age distributions to the 2001 Census for corresponding
areas, although a higher proportion of 20–24-year-old
females were recruited, and a lower proportion of
30–34-year-old males were recruited than in the popula-
tion. The proportions of males aged 20–24, 25–29 and 30–
34 in the Census population were 14%, 15% and 16%,
respectively, and for females these were 14%, 16% and
16%. Corresponding proportions for male suicide controls
were 12%, 13%, 9% and for female suicide controls were
22%, 14%, 13%.
Survey and interview format
The questionnaire was derived from standard psychiatric
and psychological instruments, the National Survey of
Mental Health and Well-being (NSMHWB), standard pop-
ulation surveys (particularly the Australian Health Survey)
and the Australian Census. The World Health Organization
Composite International Diagnostic Interview (CIDI) was
used to collect information on self-reported mental health
symptoms, which were used to score International
Classification of Diseases, 10th Revision (ICD-10) mental
disorder diagnoses (Andrews and Peters, 1998; Peters and
Andrews, 1995; Wittchen, 1994). High prevalence mental
disorders were the focus of this aspect of the study and
included substance use disorders (F10–F19), affective dis-
orders (F30–F34) and anxiety disorders (F40–F43).
The interview questions focused on the following
domains: (1) socio-demographic factors, including
income, education, occupation, employment status and
marital status, among others; and (2) psychiatric disor-
ders, particularly affective disorders. The questionnaire
was developed to be electronically collected via a laptop
computer during the interview. Cases and controls were
interviewed by trained clinical interviewers with health,
medical, social work or psychology qualifications to min-
imise interviewer and recall bias.
Variables used in analysis
The outcome variable was suicide or attempted suicide,
which were combined in order to achieve sufficient statisti-
cal power for the analysis. Past research suggests a number
of similarities in the characteristics of those who attempt
and die by suicide, including the presence of psychiatric
disorders, history of previous suicide attempts, previous
contact with services for mental health issues, social disad-
vantage and exposure to stressful life events (Beautrais,
2001, 2003). At the same time, suicide and attempted sui-
cide have a number of important differences (Mościcki,
2001). For example, those who die by suicide are more
often male and use lethal methods compared with those
who attempt suicide (Beautrais, 2001, 2003). Recognising
these differences, suicide and attempt were also assessed
separately. The main variable of interest was dismissal or
redundancy from a job in the previous 12 months (referred
to as ‘involuntary job loss’ throughout this paper), which
was ascertained through the question: ‘In the past 12
months, were you dismissed from a job or made redun-
dant?’. For suicide deaths, this question was phrased in the
third person: ‘In the 12 months before [NAME] died, was
he/she dismissed from a job or made redundant?’.
The selection of potential covariates was guided by the
development of a directed acyclic graph (Glymour, 2008)
and informed by relevant literature. Variables that were
plausible common causes (confounders) of both involun-
tary job loss and suicide and attempted suicide were
included in analyses (Glymour, 2008). Possible confound-
ing variables included age, sex and marital status (married/
de facto, never married, or separated/divorced). A diagnosis
through questionnaire of an anxiety and/or affective disor-
der using the ICD-10 codes for mild, moderate and severe
disorders (with and without somatic symptoms experienced
in the previous 12 months before the survey or interview)
was also used in the analyses. We did not include substance
use disorder as a confounder because of the concern that
this may have followed involuntary job loss (e.g. was a
mediator), rather than preceded it (Henkel, 2011). If we did
adjust for this in analysis, it raises the possibility for bias
due to conditioning on a mediator variable (Glymour,
2008).
Socio-economic status (SES) was also considered as a
potential confounder and measured through a combined
education-income measure, as described in Taylor et al.
(2004). Education was coded as an ordinal variable: high
336 ANZJP Articles
Australian & New Zealand Journal of Psychiatry, 48(4)
school education or less, post-school training such as cer-
tificate or diploma, and university qualification. Income
(AUD) was coded as annual household income: $29,999 or
less, $30,000 to $69,999, and $70,000 and over. The
income-education measure combined the three levels of
household income and education to result in an index with
five levels. The lower two categories and upper two catego-
ries were then grouped together. This produced a composite
socio-economic (SES) measure of ‘low’, ‘middle’ and
‘high’ SES groups. Bivariate analyses of the SES index
with suicide and attempts (by sex) also indicated that the
index could be reduced to three levels (low, medium and
high education-income) with reasonably homogenous odds
ratios (ORs) for the outcome variables. Information on the
scoring of the index can be seen in Supplementary Table 1.
Statistical analysis
A conditional logistic model (matching for 5-year age
group and sex, which were thus excluded as variables from
the analysis) were used to assess the effects of study varia-
bles on suicide and attempts (together and separately). The
rationale for using a conditional model was based on the
case–control matching for sex and age. This approach also
maximised statistical efficiency, which was necessary
given the relatively modest sample size of the study relative
to the number of parameters included in the statistical mod-
els. Analyses commenced with estimating unadjusted ORs
for suicide or attempts in relation to involuntary job loss.
Following this the relationship between involuntary job
loss was measured, controlling for other variables. All anal-
yses were conducted using Stata Statistical Software:
Release 12.1 (StataCorp LP, College Station, TX, USA).
Missing data and sensitivity analysis
There were a proportion of cases with information missing
on either education or income in the SES index (50 cases
out of a total of 670). In these instances information from
the non-missing variable was used in the calculation of the
index. For example, if information for a case was missing
on income but information on education was not, the index
would substitute the education information as the level of
SES. To test the possibility that this approach to missing
data biased the results, we applied two extreme scenarios:
that the missing data represented the highest and lowest
possible category of SES. We also conducted sensitivity
analysis to assess the influence of substance use disorder
(as well as anxiety or depression) on suicide and attempted
suicide to account for the possibility that substance use was
a preceding cause of both job dismissal and suicide.
The study received ethical approval from the University
of Sydney; Southern Sydney, Greater Western, Western
Sydney, Hunter New England, South Eastern Sydney
(Eastern) and South Eastern Sydney (Southern) Area Health
Services; the National Coronial Information System (NCIS);
Department of Justice Victoria; and the NSW Aboriginal
Medical Health and Research Council Ethics Committee.
Results
Within the suicide case–control analysis, there were 71
male and 13 female (n=84) suicides matched by age-strata
and sex with 223 community controls. There were 32 males
and 69 females matched with 239 community controls in
the suicide attempt case–control analysis. Results suggest
that most suicide deaths occurred among those aged 30–34
years (41.7%) and 25–29 years (33.3%). Approximately
Table 1. Involuntary job loss and suicide and attempted suicide (combined) in young adults aged 18–34 years, NSW, Australia,
2004–2010.
Unadjusted Adjusted
Case Control OR 95% CI p-value OR 95% CI p-value
Involuntary job loss Yes 28 37 2.12 1.24, 3.61 0.006 1.82 0.98, 3.37 0.058
No 157 448 1.00 1.00
Mental disorder Yes 121 91 8.49 5.74, 12.56 <0.001 7.87 5.16, 12.01 <0.001
No 64 394 1.00 1.00
Socio-economic
statusa
Low
Medium
High
107
47
31
184
146
155
3.98
1.83
1.00
2.44, 6.48
1.08, 3.09
<0.001
0.024
3.80
2.07
1.00
2.16, 6.67
1.14, 3.76
<0.001
0.016
Relationship status Separated 27 18 8.60 4.16, 17.78 <0.001 3.97 1.73, 9.13 0.001
Single 129 266 5.03 3.02, 8.37 <0.001 3.49 1.98, 6.14 <0.001
Married 29 201 1.00 0.006 1.00
Unadjusted and adjusted odds ratios (95% CIs) of suicide from conditional logistic regression. The adjusted analysis included all variables described in
the above table. Cases matched by 5-year age strata and sex.
aSocio-economic status based on a composite measure of household income and educational achievement.
Milner et al. 337
Australian & New Zealand Journal of Psychiatry, 48(4)
5% of suicides were aged 18–19 years and 20% were aged
20–24 years. Among the attempted suicides, the highest
proportion comprised those aged 20–24 years and 30–34
years (37.5% in each age group). About 9.4% were aged
18–19 years and 15.6% were aged 25–29 years.
When suicide attempts and deaths were combined in analy-
sis (Table 1), involuntary job loss was associated with signifi-
cantly greater odds of suicide and attempted suicide (OR 2.12;
95% CI 1.24 to 3.61; p=0.006). This relationship was attenu-
ated in magnitude and was non-significant following adjust-
ment for confounders (OR 1.82; 95% CI 0.98 to 3.37; p=0.058).
As can also be seen in Table 1, adjusted results indicated
that a diagnosis of affective or anxiety disorder (mental dis-
order) was associated with over a sevenfold increase in sui-
cide and attempted suicide compared to no diagnosis (OR
7.87; 95% CI 5.16 to 12.01; p<0.001). Those in the lowest
SES group had an odds ratio nearly four times greater than
those in the highest SES group (OR=3.80; 95% CI 2.16 to
6.67; p<0.001). Being separated (OR 3.97; 95% CI 1.73 to
9.13; p=0.001) or single (OR 3.49; 95% CI 1.98 to 6.14;
p<0.001) was associated with greater odds of suicide and
attempted suicide than being married.
When the data were analysed separately for suicide and
attempts, the ORs for involuntary job loss were of a similar
magnitude but there was little statistical evidence for this
association (p-values ranged from 0.062 to 0.398) (Tables 2
and 3). Mental disorder was associated with approximately
a fivefold increase (OR 5.12; 95% CI 2.49 to 10.53;
p<0.001) in suicide (death) compared to controls in the
adjusted analyses (Table 2). Those in the lowest SES group
had an odds ratio three times greater of suicide (OR=3.85;
95% CI 1.59 to 9.35; p=0.003) compared to the highest
SES group, and being separated (OR 5.44; 95% CI 1.61 to
18.39; p=0.006) or single (OR 5.84; 95% CI 2.37 to 14.39;
p<0.001) was associated with higher odds of suicide than
being married (after adjustment).
Mental disorder was associated with an OR exceeding
11 for a suicide attempt (OR 11.15; 95% CI 6.07 to 20.47;
p<0.001), and being single (OR 2.29; 95% CI 1.05 to 4.97;
p=0.036) was associated with greater odds of attempt than
being married (Table 3). Those in the lowest SES group had
greater odds of attempts compared to those in higher SES
groups (OR 3.29; 95% CI 1.57 to 6.87; p=0.002).
Sensitivity analysis
Sensitivity analysis was conducted using combined suicide
and attempt data and can be seen in Supplementary Tables
2 to 4. First, assumptions about the missing SES variables
were considered. When the missing SES values were
assumed to fall into higher SES groups, the OR for job dis-
missal decreased but the confidence intervals and p-value
were relatively unchanged (Supplementary Table 2). The
OR of suicide in relation to the lowest SES group also
decreased. The OR for job dismissal did not change sub-
stantially when the missing values were assumed to fall
into the lowest SES group (Supplementary Table 3), while
the OR for suicide in relation to membership in the lowest
SES group increased.
Analysis was also conducted on the influence of anxi-
ety, depression and substance use disorders on combined
suicide and attempts (Supplementary Table 4). There was
a 7.27 odds of suicide and attempts (95% CI 4.73 to 11.17;
p<0.001) among those with a substance use, anxiety or
depressive disorder compared to those without such disor-
ders. The OR for job dismissal reduced to non-signifi-
cance (p=0.180) after adjusting for other variables.
Compared to those in the highest SES group, there was a
Table 2. Involuntary job loss and suicide in young adults aged 18–34 years, NSW, Australia, 2004–2010.
Unadjusted Adjusted
Case Control OR 95% CIs p-value OR 95% CIs p-value
Involuntary job loss Yes 10 13 2.03 0.78, 5.29 0.149 1.60 0.54, 4.75 0.398
No 74 210 1.00 1.00
Mental disorder Yes 41 29 5.13 2.73, 9.63 <0.001 5.12 2.49, 10.53 <0.001
No 43 194 1.00 1.00
Socio-economic
statusa
Low
Medium
High
48
23
13
82
74
67
4.50
1.75
1.00
2.06, 9.82
0.77, 3.96
<0.001
0.179
3.85
1.76
1.00
1.59, 9.35
0.71, 4.41
0.003
0.224
Relationship status Separated 17 8 12.35 4.02, 37.88 <0.001 5.44 1.61, 18.39 0.006
Single 54 114 6.70 2.91, 15.43 <0.001 5.84 2.37, 14.39 <0.001
Married 13 101 1.00 0.149 1.00
Unadjusted and adjusted odds ratios (95% CIs) of suicide from conditional logistic regression. The adjusted analysis included all variables described in
the above table. Cases matched by 5-year age strata and sex.
aSocio-economic status based on a composite measure of household income and educational achievement.
338 ANZJP Articles
Australian & New Zealand Journal of Psychiatry, 48(4)
threefold increase in the odds of suicide and attempts in
the lowest SES group (OR 3.05; 95% CI 1.77 to 5.28;
p<0.001).
Discussion
The present study is based on a young adult population,
who, in Australia, have had the highest rates of unemploy-
ment in the working age-population (Australian Bureau of
Statistics, 2009; Page et al., 2013). Involuntary job loss was
associated with a twofold increase in suicide or attempted
suicide, an association which was reduced in magnitude
and to statistical non-significance following adjustment for
confounders.
Mental disorder was associated with nearly five times
the odds of suicide and 11 times the odds of a suicide
attempt. It was not possible to adequately assess whether
the mental disorder occurred before or after involuntary job
loss. Thus, we are unable to conclude the directionality of
relationships (i.e. that those with a mental illness are more
prone job, or that job loss leads to mental illness). From an
analytic point of view, controlling for mental disorder as a
common cause (i.e. confounder) is thus a conservative
approach that will underestimate the effect of involuntary
job loss on suicide and attempted suicide (Blakely et al.,
2003; Milner et al., 2013). An accurate estimate of the rela-
tionship between involuntary job loss and suicide and sui-
cide attempt is likely to be somewhere between the adjusted
and unadjusted estimates.
It is significant that distal risk factors, such as education
and income, remained significant predictors of suicide or
attempts even after controlling for mental disorder. Those in
the lowest SES group had a threefold increase in the odds of
suicide and attempted suicide compared to those in the
highest SES group. This finding supports previous literature
on the role of socio-economic disadvantage as a risk factor for
suicide (Lorant et al., 2005; Morrell et al., 1999b; Page et al.,
2002, 2006; Pan et al., 2013). We also found that those who
were separated or single had greater odds of suicide than
those who are married, which may suggest that these are asso-
ciated with greater risk compared to marriage, which could be
protective against suicide (Corcoran and Nagar, 2010).
There are a number of complexities influencing the rela-
tionship between involuntary job loss and suicide not
addressed in this study. These include pressures from the
economic environment (i.e. the availability of jobs), length
of time a person was without employment, the number of
times a person has been unemployed previously, and the
temporal relationship in the development of mental disor-
der in relation to job loss (Milner et al., 2013). Further,
although the data used in the present study represent the
largest Australian case–control study of suicide and
attempted suicide in young adults, the sample size still hin-
dered statistical power, which partly explains statistically
non-significant results when suicide and attempted suicide
were analysed separately. This was addressed by aggregat-
ing suicide and attempted suicide as the outcome and ana-
lysing both sexes together.
The study may also be subject to recall bias, as are all
case–control studies, made more problematic because of
the use of proxies (e.g. next of kin) in the suicide compo-
nent of the study (Pouliot and De Leo, 2006). However,
controls for suicides were also proxies (e.g. next of kin) in
order to maintain consistency. Suicides were enumerated
from both rural and metropolitan areas of NSW; however,
it is likely that cases from rural areas are under-represented
in this study. Aside from this limitation, we would highlight
that the gender ratio of attempts and suicides and the age
Table 3. Involuntary job loss and attempted suicide in young adults aged 18–34 years, NSW, Australia, 2004–2010.
Unadjusted Adjusted
Case Control OR 95% CIs p-value OR 95% CIs p-value
Involuntary job loss Yes 18 24 1.88 0.97, 3.64 0.062 1.67 0.76, 3.65 0.200
No 83 215 1.00 1.00
Mental disorder Yes 80 59 12.41 6.93, 22.25 <0.001 11.15 6.07, 20.47 <0.001
No 21 180 1.00 1.00
Socio-economic
statusa
Low
Med
High
59
24
18
82
69
88
3.38
1.69
1.00
1.79, 6.37
0.84, 3.40
<0.001
0.138
3.29
2.02
1.00
1.57, 6.87
0.90, 4.50
0.002
0.088
Relationship status Separated 10 10 6.06 2.17, 16.91 0.001 2.79 0.84, 9.23 0.093
Single 75 132 4.15 2.13, 8.09 <0.001 2.29 1.05, 4.97 0.036
Married 16 97 1.00 1.00
Unadjusted and adjusted odds ratios (95% CIs) of suicide from conditional logistic regression. The adjusted analysis included all variables described in
the above table. Cases matched by 5-year age strata and sex.
aSocio-economic status based on composite measure of household income and educational achievement.
Milner et al. 339
Australian & New Zealand Journal of Psychiatry, 48(4)
distribution of cases roughly correspond to nationally rep-
resentative data (Australian Bureau of Statistics, 2012;
Pirkis et al., 2000; Taylor et al., 2004). A strength of the
study (compared to previous research) (Beautrais et al.,
1997; Brent et al., 1993; Charlton, 1995; Lesage et al.,
1994) is that it used population-based cases and controls,
which reduces the likelihood of biased exposure informa-
tion and sample selection. Further, the main study factor
was involuntary job loss, which is less likely to be subject
to recall bias given this relates to a significant, sentinel
event in an individual’s employment history.
Previous international case–control studies (n=4) on sui-
cide among adolescents and young adults have been based
on relatively small sample sizes (Beautrais et al., 1997;
Brent et al., 1993; Charlton, 1995; Lesage et al., 1994) and
most have used non-population-based community controls
(Brent et al., 1993; Charlton, 1995; Lesage et al., 1994). A
number of other studies on suicide in adolescents and
young adults used record linkage cohort designs (Agerbo
et al., 2002; Christiansen et al., 2013; Niederkrotenthaler
et al., 2012; Zambon et al., 2011). While these types of
studies can provide a greater number of cases and controls
sampled from the general population, research utilising
administrative data collections (without questionnaires) are
usually unable to provide detailed information about risk
and protective factors for suicide, especially on life events
and when these occurred. The present study is significant as
it is among the first population-representative case–control
studies to provide information on the relationship between
involuntary job loss, socio-economic factors and suicide in
a sample of young adults.
The results of the present study highlight the importance
of providing timely and appropriate treatment to those with
anxiety, depression and substance use disorders. From a
wider public health approach to prevention, these findings
indicate the importance of providing targeted activities for
young people in lower SES groups. The present research is
particularly relevant in the current labour market climate of
countries affected by the global financial crisis where
involuntary job loss is an increasing problem. This empha-
sises the need for employment programs, support services
and social welfare policies to address the risk of suicide
among young adult workers who have lost their job.
Acknowledgements
We would like to acknowledge the participating hospitals: Calvary
Mater Newcastle; Prince of Wales Hospital, Randwick; Sutherland
Hospital, Caringbah; and St George Hospital, Kogarah.
Acknowledgements are also given to the coroners’ courts, as
described in the text.
Funding
This study was supported by a National Health and Medical
Research Council (NHMRC) Project Grant 301965 and by the
(Australian) Department of Health and Aging (DoHA).
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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