Written evidence submitted by Samaritans Cymru response (BSW0023)

Samaritans Cymru exists to reduce the number of people who die by suicide. In order to work towards to this goal, we have to operate within a broad spectrum; one which encompasses preventative and early intervention models alongside crisis response. The causes of suicide are complex and therefore, we work with many different services and settings, from job centres through to the police service. Each year, between 300 and 350 people die by suicide in Wales. It is the most common cause of death for men aged 20-49 and the leading cause of death for people under 35. Before the pandemic, almost a quarter of people in Wales lived in poverty and it cost Wales £3.6 bn a year; a fifth of the Welsh Government budget. New research released in 2021 indicates that Wales now has the worst child poverty rate of all the UK nations, with 1 in 5 children living below the poverty line.[1]

Suicide is an inequality issue. There is now overwhelming evidence of a strong connection between socioeconomic deprivation and suicidal behaviour. Areas of higher socioeconomic disadvantage tend to have higher rates of suicide and the greater the level of deprivation experienced by an individual, the higher their risk of suicidal behaviour.[2]

Samaritans Cymru welcomes this inquiry into the benefits system in Wales and would like to set out the following evidence which should be accounted for when analysing the challenges of the benefits system and the implications of socio-economic inequalities in Wales.

Socioeconomic disadvantage and suicidal behaviour: Finding a way forward for Wales

In 2016, we commissioned eight leading social scientists to review and extend the existing body of knowledge on this topic, addressing three key questions: Why is there a connection between socioeconomic disadvantage and suicidal behaviour? What is it about socioeconomic disadvantage that increases the risk of suicidal behaviour? What can be done about it? The research evidence was considered at three levels: societal, community and individual. In March 2017, Samaritans launched the report, titled ‘Dying from Inequality’ which examined the connection between socioeconomic disadvantage and suicidal behaviour.

Key findings from the research

Societal

Community

Individual

Social and labour market policies and suicidal behaviour

This report chapter was led by Dr Elke Heins, social policy, University of Edinburgh

Different welfare states have been shown to have different effects on social and health inequalities. High quality public service provision leads to a more cohesive society than policies based on means-testing which may generate social divisions. Given the link between inequalities and suicidal behaviour, labour market policy design can help improve wellbeing and reduce the risk of suicide.

Recognising the important role of labour market policies in shaping the experience and occurrence of unemployment and job insecurity, this report chapter examines how suicidal behaviour could be reduced through labour market policy design, exploring three main types of labour market policies in advanced welfare states:

Unemployment benefits

Generous unemployment benefits and other types of social protection can reduce the risk of suicidal behaviour. Suicide rates tend to increase in countries which implement significant budget cuts, which was evident during the 2008-09 recession in some EU countries (Karanikolos et al., 2013). Unemployment benefits compensate for some of the income loss experienced from involuntary unemployment. Depending on the level of benefits, they should help ease financial worries that may lead to suicidal behaviour. However, means-tested benefits may actually contribute to suicidal behaviour, if recipients feel stigmatised, leading to feelings of shame, worthlessness, a loss of status, and a deterioration of mental health.

Active Labour Market Programmes (ALMP)

ALMPs can help reduce suicidal behaviour. Programmes aimed at reintegrating unemployed people as quickly as possible into the labour market are likely to shorten the duration of unemployment and reduce social isolation by involving participants in training or education. They can help people find employment which is a source of social contacts, status and self-esteem, thus reducing the risk of suicidal behaviour. Higher spending on ALMPs can reduce the effect of unemployment on suicide rates in working age people, and, when spending is particularly high, the effect of unemployment on suicide rates can be counteracted altogether (Stuckler et al., 2009). However, this is dependent on participants’ perceptions of these programmes. A positive effect is more likely if the specific activity in which they are engaged is perceived as meaningful and suitable to their needs; a detrimental effect is more likely, however, if the programme is perceived as a work test without the prospect of gaining suitable employment.

Employment protection

Strong employment protection should reduce real and perceived risks around job insecurity and unemployment, resulting in a positive impact on mental health. In contrast, weak employment protection is likely to increase real and perceived insecurity, and could lead to precarious forms of employment, such as temporary or zero-hours contracts, with adverse effects on mental health. Inexperienced workers with low skills are particularly vulnerable in such contexts, since they are most likely to be on contracts which are less well protected and more precarious. The risk of mental health problems is increased among those engaged in non-traditional work situations, such as part-time, irregular, and short-term contracts with various employers, especially where there is little or no choice, as well as for those experiencing job insecurity and downsizing. Suicidal behaviour can be reduced amongst the most vulnerable in society through social and employment protection and labour market programmes. This will reduce the real and perceived risks of job insecurity and reduce stigma of unemployment.

We would also like to highlight our recent work on the effects of coronavirus on our callers. The nature of people's concerns as a result of the pandemic has changed over the year. Family, benefits, bereavement, and physical illness were strongly associated with having concerns about coronavirus.

Concerns about the financial impact of the pandemic – on income and future job prospects - have been a common theme among people contacting us. Volunteers told us financial concerns were frequently described in the context of male callers’ fears and uncertainty about the future – losing their standard of living, job loss and redundancy, or losing their business if they were self-employed.

For men in midlife, volunteers reported that feelings of shame at no longer being employed were often linked to guilt at not being able to support their family. Feeling a lack of control and powerlessness was especially common, with many male callers feeling a need to be the breadwinner and provide for their family, but unable to do this in the unstable external environment.

Another common feature of these contacts is feelings of failure and low self-worth. This is particularly common where male callers had lost their job or felt a job loss was imminent and was reported more frequently by volunteers in the summer and autumn of 2020, when the furlough scheme was expected to be wound down.

How the pandemic has affected people with pre-existing mental health conditions

While anyone can develop a mental health condition, there is a strong and persistent connection between poor mental health and financial insecurity.[3]  Research consistently shows that people in the lowest socioeconomic groups are at an increased risk of having a mental health condition, including severe conditions, and this, in turn, increases suicide risk.[4]

Socioeconomic disadvantage has many elements, but there is a particularly strong relationship between mental health and unemployment. Our volunteers report callers expressing anxieties around unemployment during the pandemic, and we know job loss can negatively affect quality of life, perceived social status, and self-esteem.[5] Research suggests that this relationship is ‘bidirectional’, with ill mental health increasing an individual’s chances of unemployment, and vice versa.[6] People who are unemployed are twice as likely to experience mental health distress compared to those in employment[7], and job loss can have an increasingly negative impact on mental health the longer it lasts.[8] Coronavirus is projected to lead to higher unemployment for years to come,[9] and those with chronic mental health conditions are more likely to lose their jobs than those without mental health problems or people with physical conditions.[10]

The relationship between unemployment, mental health, and suicide is complex, but we do know that unemployment is a risk factor for suicide[11], that people with long-term mental health conditions are more likely to become unemployed, and that this can increase the severity of their conditions.[12] A study of male mental health inpatients during the last recession found significant rises in suicide, strongly associated with unemployment.[13]  People with severe conditions may be at increased risk, as they may already be exposed to other risk factors for suicide such as social exclusion.[14] Among those with pre-existing mental health conditions, people from certain ethnic minorities may be at further risk still as they are more likely to have experienced a mental health condition in the last year, to struggle to access services, and to receive more coercive mental health care.[15]

The social security system

Increases in unemployment and financial insecurity are likely to lead to more people needing social security support. Before coronavirus, people with mental health conditions were more likely to be in receipt of certain social security payments, and some evidence suggests that this contact may negatively affect their mental wellbeing.[16]  Concerns about accessing this support were discussed frequently with us at the start of the pandemic and many callers have expressed worries about supporting themselves and their families during this period of economic disruption. People with mental health conditions report finding social security applications and meetings stressful, confusing, and anxiety-inducing[17]. Changes to the social security system, such as disability reassessments combined with the threat of sanctions, have been linked to increases in psychological distress and even suicidal thoughts amongst unemployed people.[18]  [19]

Many people with mental health conditions who come into contact with social security services during coronavirus will already have experienced risk factors for suicide, such as financial insecurity and additional emotional distress. It is crucial that these services put the wellbeing of the people using them first, with a strong foundation of equality, respect, and dignity, so that they can best contribute to reducing suicide risk

The temporary £20 per week increase to Universal Credit has been a vital lifeline to many people during the pandemic. It is due to expire in the Autumn, leaving people without this support at the same time as unemployment reaches its peak towards the end of 2021. This increase should be made permanent for everyone in receipt of Universal Credit or legacy benefits in the previous system. Wider measures are also needed to make the social security system fairer and easier to navigate for people with mental health conditions.

August 2021

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[1] Hirsch, D & Stone Local indicators of child poverty after housing costs, 2019/20

[2] Samaritans (2017) Dying from inequality: socioeconomic disadvantage and suicidal behaviour

[3] Elliott, I. (2016). Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s AntiPoverty Strategy.

[4] Samaritans. (2017). Dying from Inequality: socioeconomic disadvantage and suicidal behaviour.

[5] Mental Health Foundation. (2020). The Covid-19 pandemic, financial inequality and mental health; Gunnell, D. and Change, S.S. (2016). ‘Economic Recession, Unemployment and Suicide’, in O’Connor, R. and Pirkis, J. (Eds.) The International Handbook of Suicide Prevention, Second Edition.

[6] Institute for Work & Health. (2009). Issue briefing: Work and Mental Health.

[7] Paul, K. and Moser, K. (2009). ‘Unemployment impairs mental health: Meta-analyses’, Journal of Vocational Behaviour, 74(3), 264–82

[8] Mental Health Foundation. (2020). The COVID-19 pandemic, financial inequality and mental health.

[9] Office for Budget Responsibility. (2020). Covid-19 Analysis.

[10] Department of Work and Pensions & Department of Health and Social Care. (2017). Thriving at work: The Stevenson / Farmer review of mental health and employers.

[11] Samaritans. (2017). Dying from Inequality: socioeconomic disadvantage and suicidal behaviour.

[12] Milner, A. et al. (2014). Cause, Psychological Medicine, 44, 909-917.

[13] Ibrahim, S. et al. (2019). ‘Recession, recovery and suicide in mental health patients in England: time trend analysis’, The British Journal of Psychiatry, 215(4), 608-614

[14] Sheridan Rains, L. et al. (2020). ‘Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses’, Social Psychiatry and Psychiatric Epidemiology

[15] Barnett, P. et al. (2019). ‘Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data’, The Lancet Psychiatry, 6(4), 305-317.

[16] Greater London Authority. (2014). London Mental Health: the invisible costs of mental ill health; Parsonage, M. and Naylor, C. (2012). Mental health and physical health: a comparative analysis of costs, quality of service and cost-effectiveness.

[17] D’Arcy, C. (2020). Money and mental health at a time of crisis.

[18] Wickham, S. et al. (2020). ‘Effects on mental health of UK welfare reform, Universal Credit: a longitudinal controlled study’, The Lancet Public Health, 5(3), E157-E164. 37

[19] Barr, B. et al. (2016). ‘‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study’, Journal of Epidemiology and Community Health, 70, 339-345.