Abstract

The current crisis of capitalism has multiple economic, financial, social, environmental, cultural and political facets. In Brazil, the severity of the crisis is no different, resulting from the exhaustion of the neo-developmentalist model and its inability to resist global crisis. This study compares suicide mortality rates (MR) among employed and unemployed persons in Brazil prior to and during the economic crisis using death records from the period 2011 to 2016. The findings show that in the period 2011 to 2016 the suicide MR fell from 2.66/100,000 to 2.46 among unemployed persons and increased from 5.52/100,000 to 6.89/100,000 in employed persons. Suicide is a complex, multi-causal phenomenon determined by a diverse range of social factors, including strategies that increase worker exploitation. Indeed, being employed can have a greater negative impact on the mental health of workers than being unemployed.

Key words:
Crisis of capitalismo; Economic crisis; Unemployment; Precarious work; Suicide

Introduction

At the end of the twentieth century, capitalism underwent social and historical transformations that have significantly affected the world of work¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018.^,22 Tauss A. Contextualizing the current crisis: Post-Fordism, neoliberal restructuring, and financialization. Colomb Int 2012; (76):51-79.. After a long period of economic growth beginning in the post-war era, the 1970s were marked by stagnation of investment. A persistent drop in average profit margins was witnessed, together with a crisis of the Taylorist/Fordist accumulation pattern, explained by contradictions of the material structure of social, economic and political reproduction, which ended up undermining profits and economic expansion¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018.

2 Tauss A. Contextualizing the current crisis: Post-Fordism, neoliberal restructuring, and financialization. Colomb Int 2012; (76):51-79.

3 Fine B, Saad-Filho A. Thirteen Things You Need to Know About Neoliberalism. Crit Sociol 2017; 43(4-5):685-706.

4 Grespan J. A crise de sobreacumulação. Crítica Marx 2009; (29):11-17.^-55 Kotz DM. The financial and economic crisis of 2008: a systemic crisis of neoliberal capitalism. Rev Radic Polit Econ 2009; 41(3):305-317..

At the end of the 1970s, the Workers’ Party (Partido dos Trabalhadores - PT) emerged in Brazil, bringing together the left, working and middle classes, and intellectual segments of society. This new party expressed a new organization of formal sector workers⁶6 Saad Filho A. Avanços, contradições e limites dos governos petistas. Crítica Marx 2016; (42):171-177.. This “new organization” was the result of a considerable shift in productive activity from advanced capitalist countries to regions located in the periphery of the world capitalist system, reducing the industrial proletariat in these countries and expanding the workforce (especially in the service sector, agro-industry and industry) in various countries in the Global South¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018..

This new international division of labor was designed using measures that combined old and new forms of labor exploitation in response to the obstacles imposed on the accumulation process¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018.. In Brazil, the 1980s were characterized by the rearticulation of conservative forces, meaning that the country’s transition to democracy went hand in hand with an economic transition to neoliberalism⁶6 Saad Filho A. Avanços, contradições e limites dos governos petistas. Crítica Marx 2016; (42):171-177.. The neoliberal model may be understood as capitalism’s response to crisis, based on the articulation of strategies to promote the extraction of absolute and relative surplus-value built around super-exploitation of labor¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018..

Against this backdrop, a production restructuring process was triggered involving specific forms of exploitation that combine elements of Fordism with new mechanisms inherent in forms of flexible accumulation, transforming the economy, social structure and employment patterns in Brazil¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018.^,66 Saad Filho A. Avanços, contradições e limites dos governos petistas. Crítica Marx 2016; (42):171-177..

The global financial crisis that erupted in 2008 - one of the effects of the inherent contradictions of capitalism and patterns of accumulation developed since the 1970s, triggered by the housing bubble burst (in the subprime market) - rocked numerous financial institutions and severely impacted the real economy. This crisis was followed by a recession in the US and other countries⁵5 Kotz DM. The financial and economic crisis of 2008: a systemic crisis of neoliberal capitalism. Rev Radic Polit Econ 2009; 41(3):305-317.^,77 Carcanholo RA. A atual crise do capitalismo. Crítica Marx 2009; (29):49-55.^,88 Filgueiras L. A crise geral do capitalismo: possibilidades e limites de sua superação. Crítica Marx 2010; (30):21-27..

The unemployment caused by the recession added to “structural unemployment on a global scale”⁹9 Antunes R. Adeus ao trabalho? ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. 16ª ed. São Paulo: Cortez; 2015. (p. 264), which is not a recent phenomenon when analyzed from the perspective of advanced capitalist countries. Indeed, unemployment is a permanent outcome of the global crisis of the capitalist system, having emerged as a necessary and increasingly severe aspect of a structural crisis⁹9 Antunes R. Adeus ao trabalho? ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. 16ª ed. São Paulo: Cortez; 2015.^,1010 Mészáros I. Desemprego e "precarização flexível." In: Mészáros I. O desafio e o fardo do tempo do tempo histórico. São Paulo: Boitempo; 2007. p. 400..

Unemployment has been accompanied by worsening working terms and conditions, another capital reproduction strategy manifested in various forms: workforce commodification; poor management and work organization standards, resulting in extremely unsafe and insalubrious working conditions and employment relationships based on fear and abuse of power (moral harassment and discrimination created by outsourcing); the constant threat of unemployment; undermining of trade unions, social movements and struggles; and denial of well-established rights¹¹11 Druck G. A terceirização sem limites: mais precarização e riscos de morte aos trabalhadores. Cad Saude Publica 2016;32(6):e00146315..

Working conditions and lack of work are also important determinants of health. Within a broader concept of health, population health is determined by social, cultural, political, and economic factors that extend beyond biological and ecological dimensions. Thus, by seeking to understand the social determinants of health, various studies have assessed trends in suicidal behavior related to economic crises and the association between this behavior and unemployment and other consequences of crises¹²12 Alameda-Palacios J, Ruiz-Ramos M, García-Robredo B. Suicide, antidepressant prescription and unemployment in Andalusia (Spain). Gac Sanit 2014; 28(4):309-312.

13 Antonakakis N, Collins A. The impact of fiscal austerity on suicide: on the empirics of a modern Greek tragedy. Soc Sci Med 2014; 112:39-50.

14 Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the 2008-10 economic recession in England: Time trend analysis. BMJ 2012; 345(7873):e5142.

15 Coope C, Gunnell D, Hollingworth W, Hawton K, Kapur N, Fearn V, Wells C, Metcalfe C. Suicide and the 2008 economic recession: Who is most at risk? Trends in suicide rates in England and Wales 2001-2011. Soc Sci Med 2014; 117:76-85.

16 Córdoba-Doña JA, San Sebastián M, Escolar-Pujolar A, Martínez-Faure JE, Gustafsson PE. Economic crisis and suicidal behaviour: The role of unemployment, sex and age in Andalusia, Southern Spain. Int J Equity Health 2014; 13(1).

17 Economou M, Madianos M, Peppou LE, Theleritis C, Patelakis A, Stefanis C. Suicidal ideation and reported suicide attempts in Greece during the economic crisis. World Psych 2013; 12(1):53-59.

18 Garcy AM, Vagerö D. Unemployment and suicide during and after a deep recession: A longitudinal study of 3.4 million swedish men and women. Am J Public Health 2013; 103(6):1031-1038.

19 Hong J, Knapp M, Mcguire A. Income-related inequalities in the prevalence of depression and suicidal behaviour: A 10-year trend following economic crisis. World Psych 2011; 10(1):40-44.

20 Lopez Bernal JA, Gasparrini A, Artundo CM, McKee M. The effect of the late 2000s financial crisis on suicides in Spain: An interrupted time-series analysis. Eur J Public Health 2013; 23(5):732-736.

21 Pompili M, Vichi M, Innamorati M, Lester D, Yang B, De Leo D, Girardi P. Suicide in Italy during a time of economic recession: Some recent data related to age and gender based on a nationwide register study. Heal Soc Care Community 2014; 22(4):361-367.

22 Reeves A, McKee M, Stuckler D. Economic suicides in the Great Recession in Europe and North America. Br J Psychiatry 2014; 205(3):246-247.^-2323 Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Increase in state suicide rates in the USA during economic recession. Lancet 2012; 380(9856): 1813-1814..

Considering that Brazil has been suffering an economic crisis since 2014, characterized by a drop in Gross Domestic Product (GDP) between 2014 and 2016, rising unemployment rates (2014 - 6.8%; 2015 - 8.5%; 2016 - 11.5%; 2017 - 12.7%)²⁴24 Instituto Brasileiro de Geografia e Estatística (IBGE). Coordenação de População e Indicadores Sociais. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira: 2018/IBGE [Internet]. Rio de Janeiro: IBGE; 2018 [acessado 2019 jul 27]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101629.pdf and fiscal austerity policies, reducing the provision of social protection services²⁵25 Vieira FS. Crise econômica, austeridade fiscal e saúde: que lições podem ser aprendidas? [Internet]. Brasília: Instituto de Pesquisa Econômica Aplicada; 2016. [acessado 2019 jul 27]. Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/160822_nt_26_disoc.pdf^,2626 Mathias M. A crise por trás da nova PNAB. Rev Poli Saude Educ Trab [Internet]. Rio de Janeiro: EPSJV/Fiocruz; 2017;(53):6-13. [acessado 2019 jul 27]. Disponível em: http://www.epsjv.fiocruz.br/sites/default/files/poliweb53.pdf, it is important to study the impact of high unemployment rates on suicide, which in turn is a key indicator of population health.

The aim of this study was therefore to estimate the suicide mortality rate in the Brazil population and compare rates among employed and unemployed persons prior to (2011 to 2013) and during (2014 to 2016) the economic crisis.

Methods

We conducted a mortality study based on secondary data using records of suicide deaths in the period 2011 to 2016. Only individuals aged 18 years and over were included in the sample.

This data is publicly available from the Mortality Information System (SIM/MS 2011-2016), which is part of the country’s national health information system (DATASUS). Deaths are coded according the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)²⁷27 Centro Colaborador da OMS para a Classificação de Doenças em Português (CBCD). Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde - CID-10 [Internet]. [acessado 2018 set 19]. Disponível em: http://www.datasus.gov.br/cid10/V2008/cid10.htm
http://www.datasus.gov.br/cid10/V2008/ci... . The population data were obtained from the National Household Sample Survey (PNAD)²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Sistema IBGE de Recuperação Automática (SIDRA). Pesquisa Nacional por Amostra de Domicílios [Internet]. Rio de Janeiro: IBGE; 2015 [acessado 2019 jul 27]. Disponível em: https://sidra.ibge.gov.br/pesquisa/pnad and Continuous National Household Sample Survey (PNAD Contínua)²⁹29 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios Contínua - PNAD Contínua [Internet]. [acessado 2019 jul 27]. Disponível em: https://www.ibge.gov.br/estatisticas-novoportal/sociais/trabalho/9171-pesquisa-nacional-por-amostra-de-domicilios-continua-mensal.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas-nov... , which are publicly available on the Brazilian Institute of Geography and Statistics’ (IBGE) website.

Considering that Brazil witnessed a drop in GDP³⁰30 Ipeadata. Brasil - Produto interno bruto (PIB): conceito de paridade do poder de compra (PPC) per capita [Internet]. 2020 [acessado 2020 fev 10]. Disponível em: http://www.ipeadata.gov.br/Default.aspx
http://www.ipeadata.gov.br/Default.aspx... per capita and rise in unemployment between 2014 and 2016, constituting a recession, we used 2014 as the baseline date for beginning of the crisis, delimiting the study period into two specific periods: economic crisis (2014-2016) and prior to the crisis (2011-2013).

The concept of working class refers to individuals who sell their labor power to earn a living. However, it is important to highlight that official statistics confuse this concept, as the classification of labor force includes both employed and unemployed persons, and the category employed includes all persons who participate in economic activity, including people who sell their labor power (workers) and those who purchase this labor power (employers). This means that employers - owners of the means of production - appear together with workers³¹31 Manzano S. Quem é a classe trabalhadora brasileira? Blog da Boitempo [Internet]. 2019 [acessado 2020 fev 11]. Disponível em: https://blogdaboitempo.com.br/2019/12/03/quem-e-a-classe-trabalhadora-brasileira/
https://blogdaboitempo.com.br/2019/12/03... .

The outcome variable (suicide) was defined according to the following ICD-10 primary cause (<primcaus>) of death codes: intentional self-harm (X60 to X84), poisoning of undetermined intent (Y10 to Y19) and sequelae of intentional self-harm (Y87.0). All other causes of death were classified as non-suicide. It is important to highlight that suicide by poisoning is underreported due to shortcomings in cause coding³²32 Rockett IR, Hobbs G, De Leo D, Stack S, Frost JL, Ducatman AM, Kapusta ND, Walker RL. Suicide and unintentional poisoning mortality trends in the United States, 1987-2006: Two unrelated phenomena? BMC Public Health 2010; 10.^,3333 Santos SA, Legay LF, Aguiar FP, Lovisi GM, Abelha L, Oliveira SP. Suicide and suicide attempts by exogenous poisoning in Rio de Janeiro, Brazil: Information analysis through probabilistic linkage | Tentativas e suicídios por intoxicação exógena no Rio de Janeiro, Brasil: Análise das informações através do linkage probab. Cad Saude Publica 2014; 30(5):1057-1066..

The variable occupation (<occup>) was the person’s regular occupation recorded on the death certificate according to the codes used in the Brazilian Classification of Occupations (CBO/2002)³⁴34 Classificação Brasileira de Ocupações (CBO). Portaria no 397, de 09 de outubro de 2002 - 5.1.0. Aprova a Classificação Brasileira de Ocupações - CBO/2002, para uso em todo território nacional e autoriza a sua publicação. [Internet]. [acessado 2020 jan 20]. Disponível em: http://www.mtecbo.gov.br/cbosite/pages/legislacao.jsf
http://www.mtecbo.gov.br/cbosite/pages/l... . Although included in the SIM/MS, the category unemployed (code 999994 defined by the DATASUS)³⁵35 Brasil. Ministério da Saúde (MS). Manual de Instruções para o preenchimento da Declaração de Óbito. Brasília: MS; 2011 [Internet]. [acessado 2020 jan 20]. Disponível em: http://svs.aids.gov.br/download/manuais/Manual_Instr_Preench_DO_2011_jan.pdf is not one of the occupations included in the CBO/2002³⁴34 Classificação Brasileira de Ocupações (CBO). Portaria no 397, de 09 de outubro de 2002 - 5.1.0. Aprova a Classificação Brasileira de Ocupações - CBO/2002, para uso em todo território nacional e autoriza a sua publicação. [Internet]. [acessado 2020 jan 20]. Disponível em: http://www.mtecbo.gov.br/cbosite/pages/legislacao.jsf
http://www.mtecbo.gov.br/cbosite/pages/l... . Thus, since the death certificate only records “regular occupation” and not occupational status, the fact that the individual was unemployed often goes unrecorded³⁷37 Cordeiro R, Peñaloza ER, Cardoso CF, Cortez DB, Kakinami E, Souza JJ, Souza MT, Fernandes RA, Guercia RF, Adoni T. Validity of information on occupation and principal cause on death certificates in Botucatu, São Paulo. Cad Saude Publica 1999; 15(4):719-728..

Other factors potentially associated with suicide were also analyzed. These covariates comprised the following sociodemographic and economic characteristics: sex, age, race/skin color (white, black, yellow, brown and indigenous), marital status (single, married, widowed or divorced) and education level. Not all factors associated with risk of suicide were analyzed because the SIM data used in this study include only a limited number of variables.

Mortality was measured using the suicide mortality rate (MR) per 100,000 population among employed and unemployed persons, calculated by dividing the number of suicide deaths by the total number of employed and unemployed persons in the country. Suicide MR was calculated by occupational status, considering other covariates.

A descriptive analysis was conducted using absolute and relative frequencies. The analyses were performed using Stata version 12.0 (Stata Corporation, College Station, USA).

Results

A total of 62,950 suicide deaths were recorded during the study period, 30,493 of which occurred between 2011 and 2013 and 32,457 in the period 2014 to 2016. In both periods men accounted for the highest proportion of deaths: 79.19% prior to the crisis, and 79.91% during the economic crisis. The age groups that accounted for the highest proportion of deaths prior and during crisis were the 25-39 and 40-59 years groups, respectively (Table 1).

The proportion of suicide deaths was higher among white people in both periods, although the largest percentage change between the two periods was found among the indigenous group. With regard to “education level”, people with at least eight years of formal education accounted for the highest proportion of suicides both prior to (26.05%) and during the crisis (31.30%) and also showed the largest percentage change (20.15%) between the two periods.

With regard to marital status, suicides as share of total deaths varied only slightly between the two periods across all categories. With regard to occupation, most of the study sample were recorded as having a “regular occupation”. The percentage change between the two periods in this group was + 1.49%. Although relatively few people were recorded as unemployed, this group showed the highest increase in number of suicide deaths between the periods (from 457 in the period 2011-2013 to 728 in the period 2014-2016) (Table 1).

Despite this increase, suicide MR was greater among people recorded as having an occupation than those whose occupation was recorded as unemployed in both study periods. During the period 2011-2013, the percentage change in suicide MR was + 4.3% among people recorded as having an occupation and + 51% in those recorded as unemployed. During the period 2014-2016, the suicide MR rose by 25.0% among people recorded as having an occupation and decreased by 43% among those recorded as unemployed. The highest suicide MR was in 2014 for people recorded as unemployed and 2016 for those recorded as having an occupation (4.31/100,000 and 6.89/100,000, respectively) (Graph 1).

In general, the male suicide MR was higher among men recorded as having an occupation than those recorded as unemployed. The highest suicide MR was in 2014 for men recorded as unemployed and 2016 for those recorded as having an occupation (11.46/100,000 and CM 10,39/100,000, respectively). During the period prior to the crisis, the suicide MR rose by 4.8% in men recorded as having an occupation and 54.5% in those recorded as unemployed. During the crisis, the suicide MR increased by 21.6% in men recorded as having an occupation and dropped by 62.3% among those recorded as unemployed (Graph 2).

The female suicide MR was higher among women recorded as having an occupation than those recorded as unemployed throughout the whole study period (Graph 3). At the start of the period (2011), the suicide MR among women recorded as having an occupation and those recorded as unemployed was 1.77/100,000 and 0.63/100,000, respectively. During the crisis, the suicide MR increased 30.3% in women recorded as having an occupation and fell by 7.1% among those recorded as unemployed (Graph 3).

With regard to the recorded occupations of suicide cases, the majority of the individuals were agricultural workers (2011-2013: 23.17%; 2014-2016: 20.97%), followed by extractive industry and construction workers (2011-2013: 15.06%; 2014-2016: 14.81%), service workers (2011-2013: 13.43%; 2014-2016: 13.47%) and cross-functional role workers (2011-2013: 6.22%; 2014-2016: 6.40%) (Table 2).

Discussion

Our findings show that the suicide MR was higher in men than in women. Studies in European countries conducted after 2008³⁸38 Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ Open 5(3):e007295.

39 Branas CC, Kastanaki AE, Michalodimitrakis M, Tzougas J, Kranioti EF, Theodorakis PN, Carr BG, Wiebe DJ. The impact of economic austerity and prosperity events on suicide in Greece: A 30-year interrupted time-series analysis. BMJ Open 2015;5(1).^-4040 Kontaxakis V, Papaslanis T, Havaki-Kontaxaki B, Tsouvelas G, Giotakos O, Papadimitriou GN. Suicide in Greece: 2001-2011. Psychiatrike 2013; 24(3):170-174. and other studies in Brazil⁴¹41 Bando DH, Lester D. An ecological study on suicide and homicide in Brazil | Estudo ecológico sobre suicídio e homicídio no Brasil. Cien Saude Colet 2014; 19(4):1179-1189.^,4242 Jaen-Varas D, Mari JJ, Asevedo E, Borschmann R, Diniz E, Ziebold C, Gadelha A. The association between adolescent suicide rates and socioeconomic indicators in brazil: A 10-year retrospective ecological study. Brazilian J Psychiatry 2019;41(5):389-395. have also reported that suicide is more common in men. The higher rate of suicide among men may be associated with factors such as impulsivity, aggressiveness, psychoactive substance use⁴³43 Cuadrado C, Zitko P, Covarrubias T, Hernandez D, Sade C, Klein C, Gomez A. Association between adolescent suicide and sociodemographic factors in Chile: Cross-sectional ecological study. Crisis 2015; 36(4):281-290.

44 Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2003; 42(4):386-405.^-4545 Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: A national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003; 160(4):765-772., and use of more lethal suicide methods⁴⁶46 Machado DB, dos Santos DN. Suicide in brazil, from 2000 to 2012 | Suicídio no Brasil, de 2000 a 2012. J Bras Psiquiatr 2015; 64(1):45-54.^,4747 Macente LB, Zandonade E. Estudo da série histórica de mortalidade por suicídio no Espírito Santo (de 1980 a 2006). J Bras Psiquiatr 2011; 60(3):151-157..

We observed a negative percentage change in suicide MR during the period of crisis in people recorded as unemployed. In a study examining the relationship between suicide rates and economic indicators (GDP per capita and unemployment rates) in major urban centers in Brazil between 2006 and 2015, Asevedo et al. found a correlation between a reduction in unemployment rates and higher suicide rates⁴⁸48 Asevedo E, Ziebold C, Diniz E, Gadelha A, Mari J. Ten-year evolution of suicide rates and economic indicators in large Brazilian urban centers. Curr Opin Psychiatry 2018; 31(3):265-271.. Another study in Brazil, undertaken by Bando et al. in 2010, found higher suicide rates in regions with high per capita income and lower rates of unemployment, suggesting that suicide is more common in regions with higher quality of life⁴¹41 Bando DH, Lester D. An ecological study on suicide and homicide in Brazil | Estudo ecológico sobre suicídio e homicídio no Brasil. Cien Saude Colet 2014; 19(4):1179-1189.. These results are consistent with our findings. However, these studies used aggregate data⁴¹41 Bando DH, Lester D. An ecological study on suicide and homicide in Brazil | Estudo ecológico sobre suicídio e homicídio no Brasil. Cien Saude Colet 2014; 19(4):1179-1189.^,4848 Asevedo E, Ziebold C, Diniz E, Gadelha A, Mari J. Ten-year evolution of suicide rates and economic indicators in large Brazilian urban centers. Curr Opin Psychiatry 2018; 31(3):265-271., which is a limitation because this type of data does not show the effect of unemployment at the individual level.

Machado et al. on the other hand showed that income inequality is a determinant of suicide in Brazil. They showed that the increase in suicide rates between 2000 and 2011 was lower than in previous periods, attributing this effect to a reduction in social inequality, fall in the proportion of individuals who did not complete primary education, and rise in income⁴⁹49 Machado DB, Rasella D, Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015; 10(4):e0124934..

Studies analyzing the relationship between socioeconomic indicators and suicide suggest that unemployment resulting from economic crisis and fiscal austerity measures contributes to an increase in suicide rates¹³13 Antonakakis N, Collins A. The impact of fiscal austerity on suicide: on the empirics of a modern Greek tragedy. Soc Sci Med 2014; 112:39-50.^,1515 Coope C, Gunnell D, Hollingworth W, Hawton K, Kapur N, Fearn V, Wells C, Metcalfe C. Suicide and the 2008 economic recession: Who is most at risk? Trends in suicide rates in England and Wales 2001-2011. Soc Sci Med 2014; 117:76-85.^,1616 Córdoba-Doña JA, San Sebastián M, Escolar-Pujolar A, Martínez-Faure JE, Gustafsson PE. Economic crisis and suicidal behaviour: The role of unemployment, sex and age in Andalusia, Southern Spain. Int J Equity Health 2014; 13(1).^,2020 Lopez Bernal JA, Gasparrini A, Artundo CM, McKee M. The effect of the late 2000s financial crisis on suicides in Spain: An interrupted time-series analysis. Eur J Public Health 2013; 23(5):732-736.^,2525 Vieira FS. Crise econômica, austeridade fiscal e saúde: que lições podem ser aprendidas? [Internet]. Brasília: Instituto de Pesquisa Econômica Aplicada; 2016. [acessado 2019 jul 27]. Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/160822_nt_26_disoc.pdf^,3838 Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ Open 5(3):e007295.^,3939 Branas CC, Kastanaki AE, Michalodimitrakis M, Tzougas J, Kranioti EF, Theodorakis PN, Carr BG, Wiebe DJ. The impact of economic austerity and prosperity events on suicide in Greece: A 30-year interrupted time-series analysis. BMJ Open 2015;5(1).^,5050 Chang S-S, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: Time trend study in 54 countries. BMJ 2013; 347(7925).^,5151 Modrek S, Stuckler D, McKee M, Cullen MR, Basu S. A Review of Health Consequences of Recessions Internationally and a Synthesis of the US Response during the Great Recession. Public Health Reviews 2013(10). DOI: https://doi.org/10.1007/BF03391695
https://doi.org/10.1007/BF03391695... . Our results however indicate that people recorded as employed are more exposed to the risk of dying by suicide than those recorded as unemployed.

This increased risk of dying by suicide among people recorded as having an occupation may be related to the changes that have taken place in the world of work in recent decades. Psychic suffering linked to work is a direct result of the destructive logic of capitalism, which fails to limit precarious employment, exploiting the workforce to the extreme, while shortening time of use and making workers disposable (since many workers end up being left with a permanent incapacity for work)⁵²52 Antunes R, Praun L. A sociedade dos adoecimentos no trabalho. Serviço Soc Soc FapUNIFESP 2015; (123):407-427..

The global dissemination of work and production reorganization processes, combined with the expansion of different forms of precarious work, such as the growth in outsourcing, moral harassment, management by objectives, and stripping away of workers’ rights, is related to the increasing incidence of mental distress among workers⁵²52 Antunes R, Praun L. A sociedade dos adoecimentos no trabalho. Serviço Soc Soc FapUNIFESP 2015; (123):407-427. and, possibly, increased risk of death by suicide.

It is worth highlighting two other similarities with other studies: the increase in suicide MR during the period of crisis¹⁴14 Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the 2008-10 economic recession in England: Time trend analysis. BMJ 2012; 345(7873):e5142.^,2020 Lopez Bernal JA, Gasparrini A, Artundo CM, McKee M. The effect of the late 2000s financial crisis on suicides in Spain: An interrupted time-series analysis. Eur J Public Health 2013; 23(5):732-736.^,3838 Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ Open 5(3):e007295.^,5353 Alicandro G, Malvezzi M, Gallus S, La Vecchia C, Negri E, Bertuccio P. Worldwide trends in suicide mortality from 1990 to 2015 with a focus on the global recession time frame. Int J Public Health 2019; 64(5):785-795.

54 Chan CH, Caine ED, You S, Fu KW, Chang SS, Yip PSF. Suicide rates among working-age adults in South Korea before and after the 2008 economic crisis. J Epidemiol Community Health 2014; 68(3):246-252.

55 Corcoran P, Griffin E, Arensman E, Fitzgerald AP, Perry IJ. Impact of the economic recession and subsequent austerity on suicide and self-harm in Ireland: An interrupted time series analysis. Int J Epidemiol 2015; 44(3):969-977.

56 Madianos MG, Alexiou T, Patelakis A, Economou M. Suicide, unemployment and other socioeconomic factors: Evidence from the economic crisis in Greece. Eur J Psychiatry 2014; 28(1):39-49.^-5757 Tapia Granados JA, Rodriguez JM. Health, economic crisis, and austerity: A comparison of Greece, Finland and Iceland. Health Policy 2015;119(7):941-953. and the high proportion of suicides among agricultural workers⁵⁸58 Freire C, Koifman S. Pesticides, depression and suicide: A systematic review of the epidemiological evidence. Int J Hyg Environ Health 2013; 216(4):445-460.

59 Pires DX, Caldas ED, Recena MC. Intoxicações provocadas por agrotóxicos de uso agrícola na microrregião de Dourados, Mato Grosso do Sul, Brasil, no período de 1992 a 2002. Cad Saude Publica 2005; 21(3):804-814.^-6060 Meyer A, Koifman S, Koifman RJ, Moreira JC, Rezende Chrisman J, Abreu-Villaça Y. Mood disorders hospitalizations, suicide attempts, and suicide mortality among agricultural workers and residents in an area with intensive use of pesticides in Brazil. J Toxicol Environ Health 2010;73(13-14):866-877.. In a study in Rio de Janeiro, Meyer et al. showed that SM was higher in people living in rural areas, particularly among agricultural workers. The findings suggest that workers living in areas of intensive use of pesticides were at greater risk of SM, which may be explained by increased risk of depression and attempted suicide due to continuous exposure to these neurotoxic compounds⁶⁰60 Meyer A, Koifman S, Koifman RJ, Moreira JC, Rezende Chrisman J, Abreu-Villaça Y. Mood disorders hospitalizations, suicide attempts, and suicide mortality among agricultural workers and residents in an area with intensive use of pesticides in Brazil. J Toxicol Environ Health 2010;73(13-14):866-877..

However, our findings are not consistent with the results of studies showing that risk of suicide was greater among businesspersons and high-ranking employees during the economic crisis⁵⁴54 Chan CH, Caine ED, You S, Fu KW, Chang SS, Yip PSF. Suicide rates among working-age adults in South Korea before and after the 2008 economic crisis. J Epidemiol Community Health 2014; 68(3):246-252.^,6161 Mattei G, Ferrari S, Pingani L, Rigatelli M. Short-term effects of the 2008 Great Recession on the health of the Italian population: An ecological study. Soc Psychiatry Psychiatr Epidemiol 2014; 49(6):851-858..

The difference between our findings and those of other studies regarding unemployment may be related to the use of different methods. In this respect, it is important to stress that the SIM data used in the present study focus on regular occupation rather than occupational status.

Suicide is a complex, multi-causal phenomenon determined by a diverse range of social factors, including the super-exploitation of labor¹1 Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. 1ª ed. São Paulo: Boitempo; 2018. (e.g.: employee performance appraisals, increasingly demanding productivity targets, moral harassment etc.), which in turn adversely affects workers’ health and contributes to psychic suffering.

Finally, it is important to highlight two methodological limitations of the present study. First, we did not include other well-documented suicide risk factors. The second limitation is the low level of data completeness (for example, race/skin color, education level, marital status and occupational status) and inconsistencies in the variable “regular occupation” as a measure of occupational status.

Conclusions

This study investigated the relationship between unemployment (as recorded in the field “regular occupation” in the SIM) and suicide, comparing two periods: prior to (2011-2013) and during (2014-2016) the economic crisis. We did not observe an increase in suicide MR among people recorded as unemployed, unlike in other countries, notably Greece after 2008. However, this result does not mean that unemployment is a protective factor against suicide. Rather, it may suggest that the working conditions imposed by the new morphology of labor (for example, stripping away of workers’ rights, informality and generally precarious working conditions) expose employed persons to a greater risk of dying by suicide than the unemployed.

The consequences of the social metabolism of capital for the world of work have effects on people’s way of life, which materialize in the direct relationship between work and health, leading to physical and/or mental illness among workers around the world.

In view of the above, it is not enough to think about strategies to mitigate the crisis of capitalism, minimizing its impacts on people’s health. Transforming this reality poses the following challenge: to create a form of social organization that eliminates the super-exploitation of labor, dismantling the process of capital accumulation through measures that break with the logic of capitalism and contribute to the emancipation of humanity and planetary sustainability.

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