Abstract

This article aims to examine differences in suicidal narrative and suicide crisis syndrome symptoms, and suicidal ideation among those who maintained, lost, and gained employment or student status during the COVID-19 pandemic. It is a cross-sectional study based on an online and anonymous self-report questionnaire. Participants were recruited through social media platforms between November 2020 and October 2021. Changes in occupational status were assessed in 2,259 individuals. The sample was divided into four groups according to work (full-time/part-time) and study status (1) maintained, (2) lost, (3) gained, and (4) unemployed. Suicide outcomes were investigated by the Suicidal Narrative Inventory, Suicide Crisis Inventory, and Columbia - Suicide Severity Rating Scale Screener version. Changes in occupational status influenced symptoms of the suicide crisis syndrome and suicidal narrative, but not suicidal ideation. Those who maintained their work, such as full-time/part-time scored lower on the total scores of the Suicidal Narrative Inventory and Suicide Crisis Inventory-2 compared to those who lost their employed status and unemployed. Our findings suggest that it is appropriate to consider changes in employed status as a mental health risk factor during pandemics.

Key words:
Changes in occupation; Mental health; Suicidal ideation

Resumo

O objetivo do artigo é examinar diferenças nos sintomas da narrativa suicida e da síndrome de crise de suicídio e ideação suicida entre aqueles que mantiveram, perderam e ganharam emprego ou status educacional durante a pandemia de COVID-19. Trata-se de um estudo transversal baseado em um questionário online. Os indivíduos foram recrutados por meio de plataformas de mídia social entre novembro de 2020 e outubro de 2021. As mudanças no status ocupacional foram avaliadas em 2.259 indivíduos. A amostra foi dividida em grupos de acordo com as mudanças do status ocupacional: (1) aqueles que mantiveram, (2) aqueles que perderam, (3) aqueles que ganharam e (4) desempregados. Desfechos suicidas foram avaliados através do Inventário da Narrativa Suicida, Inventário da Crise Suicida e Columbia - Escala de Classificação da Gravidade do Suicídio. Mudanças no status ocupacional influenciaram sintomas da síndrome de crise de suicídio e narrativa suicida, mas não a ideação suicida. Aqueles que mantiveram seu emprego apresentaram menos sintomas de narrativa suicida e síndrome de crise de suicídio, comparados aos que perderam o emprego e aos desempregados. Esses achados sugerem que é apropriado considerar mudanças no status ocupacional como fator de risco para saúde mental durante pandemias.

Palavras-chave:
Mudanças na ocupação; Saúde mental; Ideação suicida

Introduction

The lockdowns positively controlled the COVID-19 pandemic, with a more significant effect in countries where confinement started early and was more restrictive¹1 Caristia S, Ferranti M, Skrami E, Raffetti E, Pierannunzio D, Palladino R, Carle F, Saracci R, Badaloni C, Barone-Adesi F, Belleudi V, Ancona C; AIE working group on the evaluation of the effectiveness of lockdowns. Effect of national and local lockdowns on the control of COVID-19 pandemic: a rapid review. Epidemiol Prev 2020; 44(5-6 Suppl. 2):60-68.. Previous studies demonstrated that insecurity at work, long periods of isolation, and uncertainty about the future worsened the psychological situation²2 Flanagan EW, Beyl RA, Fearnbach SN, Altazan AD, Martin CK, Redman LM. The impact of COVID-19 stay-at-home orders on health behaviors in adults. Obesity (Silver Spring) 2021; 29(2):438-445.

3 Rogers ML, Cao E, Richards JA, Mitelman A, Barzilay S, Blum Y, Chistopolskaya K, Çinka E, Dudeck M, Husain MI, Kantas Yilmaz F, Kusmirek O, Luiz JM, Menon V, Nikolaev EL, Pilecka B, Titze L, Valvassori SS, You S, Galynker I. Changes in daily behaviors and cognitions during the COVID-19 Pandemic: associations with suicide crisis syndrome and suicidal ideation. Clin Psychol Sci 2023; DOI: 10.1177/21677026221148732.
https://doi.org/10.1177/2167702622114873...

4 Boehm M, White A, Bleakley A, Young DG. How stay-at-home orders interact with COVID-19 misperceptions and individuals' social distancing intentions. J Prev 2022; 43(4):469-484.

5 Cuadrado E, Arenas A, Moyano M, Tabernero C. Differential impact of stay-at-home orders on mental health in adults who are homeschooling or "childless at home" in time of COVID-19. Fam Process 2022; 61(2):722-744.

6 Giorgi G, Lecca LI, Alessio F, Finstad GL, Bondanini G, Lulli LG, Arcangeli G, Mucci N. COVID-19-related mental health effects in the workplace: a narrative review. Int J Environ Res Public Health 2020; 17(21):7857.^-77 Chen J, Zhang SX, Yin A, Yáñez JA. Mental health symptoms during the COVID-19 pandemic in developing countries: a systematic review and meta-analysis. J Glob Health 2022; 12:05011.. In Brazil, the outbreak has exacerbated existing health, political, economic, and social problems⁸8 Sott MK, Bender MS, Silva Baum K. COVID-19 outbreak in Brazil: Health, social, political, and economic implications. Int J Health Serv 2022; 52(4):442-454.. In the first quarter of the pandemic, there were 14.805 million unemployed in Brazil⁹9 Paiva CC, Paiva SCF. No Brasil, impacto econômico da pandemia será forte e duradouro [Internet]. 2021. [acessado 2023 ago 3]. Disponível em: https://jornal.unesp.br/2021/07/02/no-brasil-impacto-economico-da-pandemia-sera-forte-e-duradouro/
https://jornal.unesp.br/2021/07/02/no-br... . Furthermore, it is estimated that up to 1.7 million jobs were reduced, with the lower socio-economic strata of the population bearing the most problematic consequences¹⁰10 Barros A. Com pandemia, 20 estados têm taxa média de desemprego recorde em 2020 [Internet]. 2021. [acessado 2023 ago 3]. Disponível em: https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/30235-com -pandemia-20-estados-tem-taxa-media-de-desemprego-recorde-em-2020#:~:text=Com%20pandemia%2C%2020%20estados%20t%C3%AAm%20taxa%20m%C3%A9dia%20de%20desemprego%20recorde%20em%202020,-Editoria%3A%20Estat%C3%ADsticas%20Sociais&text=A%20taxa%20m%C3%A9dia%20de%20desocupa%C3%A7%C3%A3o,PNAD%20Cont%C3%ADnua%2C%20iniciada%20em%202012.
https://agenciadenoticias.ibge.gov.br/ag... . Individuals who lost their jobs and income reduction had to deal with limited resources and change their routines to deal with numerous new challenges¹¹11 Wei X, Li L, Zhang F. The impact of the COVID-19 pandemic on socio-economic and sustainability. Environ Sci Pollut Res Int 2021; 28(48):68251-68260.^,1212 Clemens V, Deschamps P, Fegert JM, Anagnostopoulos D, Bailey S, Doyle M, Eliez S, Hansen AS, Hebebrand J, Hillegers M, Jacobs B, Karwautz A, Kiss E, Kotsis K, Kumperscak HG, Pejovic-Milovancevic M, Christensen AMR, Raynaud JP, Westerinen H, Visnapuu-Bernadt P. Potential effects of "social" distancing measures and school lockdown on child and adolescent mental health. Eur Child Adolesc Psychiatry 2020; 29(6):739-742..

Occupational status and educational level are critical markers of success in adulthood¹³13 Slominski L, Sameroff A, Rosenblum K, Kasser T. Longitudinal predictors of adult socioeconomic attainment: the roles of socioeconomic status, academic competence, and mental health. Dev Psychopathol 2011; 23(1):315-324.. In previous studies, occupational status was a determinant of worse self-rated health, addictions, and poor mental health outcomes¹⁴14 Blanquet M, Labbe-Lobertreau E, Sass C, Berger D, Gerbaud L. Occupational status as a determinant of mental health inequities in French young people: is fairness needed? Results of a cross-sectional multicentre observational survey. Int J Equity Health 2017;16(1):142.. Castelpietra et al. showed that employment is a protective factor for psychiatric hospitalizations and the diagnosis of severe mental disorders¹⁵15 Castelpietra G, Balestrieri M, Bovenzi M. Occupational status and hospitalisation for mental disorders: findings from Friuli Venezia Giulia region, Italy, 2008-2017. Int J Psychiatry Clin Pract 2019; 23(4):265-272.. Regardless, certain occupational groups are at elevated risk of suicide compared with the general employed population (e.g., laborers, cleaners, machine operators, and agricultural workers)¹⁶16 Milner A, Spittal MJ, Pirkis J, LaMontagne AD. Suicide by occupation: systematic review and meta-analysis. Br J Psychiatry 2013; 203(6):409-416.. Nonetheless, most studies still have not investigated if changes in occupational status can be associated with suicidal ideation in the general population. Understanding the impacts of occupational status changes (e.g., work and study) through a theoretical framework can help to elucidate the relationship between work/education changes and suicide-related outcomes.

The Narrative-Crisis Model is one such model, which is a stepwise model of the progression from chronic to near-term suicidal risk. This model comprises three central components: chronic risk factors, suicidal narrative, and suicide crisis syndrome (SCS)¹⁷17 Galynker I. The Suicidal Crisis. Oxford: Oxford University Press; 2017.^,1818 Pia T, Galynker I, Schuck A, Sinclair C, Ying G, Calati R. Perfectionism and prospective near-term suicidal thoughts and behaviors: the mediation of fear of humiliation and Suicide Crisis Syndrome. Int J Environ Res Public Health 2020; 17(4):1424.. The SCS is a negative cognitive-affective state associated with imminent suicidal behavior in those at high risk for suicide¹⁷17 Galynker I. The Suicidal Crisis. Oxford: Oxford University Press; 2017.. The SCS comprises several interrelated symptoms, including entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal¹⁹19 Bloch-Elkouby S, Gorman B, Schuck A, Barzilay S, Calati R, Cohen LJ, Begum F, Galynker I. The suicide crisis syndrome: a network analysis. J Couns Psychol 2020; 67(5):595-607.. Indeed, SCS is proposed as a unidimensional syndrome that proved promising as a new suicide-specific condition²⁰20 Cohen LJ, Ardalan F, Yaseen Z, Galynker I. Suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav 2018; 48(5):613-623.

21 Schuck A, Calati R, Barzilay S, Bloch-Elkouby S, Galynker I. Suicide Crisis Syndrome: a review of supporting evidence for a new suicide-specific diagnosis. Behav Sci Law 2019; 37(3):223-239.^-2222 Yaseen ZS, Hawes M, Barzilay S, Galynker I. Predictive validity of proposed diagnostic criteria for the suicide crisis syndrome: an acute presuicidal state. Suicide Life Threat Behav 2019; 49(4):1124-1135.. Individuals with chronic risk factors for suicide are likely to develop a subacute cognitive state of self-concerning others, termed suicidal narrative²³23 Cohen LJ, Gorman B, Briggs J, Jeon ME, Ginsburg T, Galynker I. The suicidal narrative and its relationship to the suicide crisis syndrome and recent suicidal behavior. Suicide Life Threat Behav 2019; 49(2):413-422.^,2424 Cohen LJ, Mokhtar R, Richards J, Hernandez M, Bloch-Elkouby S, Galynker I. The Narrative-Crisis Model of suicide and its prediction of near-term suicide risk. Suicide Life Threat Behav 2022; 52(2):231-243.. The suicidal narrative progresses from the frustration of treasured goals and the inability to re-orient toward new, more feasible goals to feelings of social defeat, humiliation, thwarted belongingness, and perceived burdensomeness¹⁷17 Galynker I. The Suicidal Crisis. Oxford: Oxford University Press; 2017.^,2424 Cohen LJ, Mokhtar R, Richards J, Hernandez M, Bloch-Elkouby S, Galynker I. The Narrative-Crisis Model of suicide and its prediction of near-term suicide risk. Suicide Life Threat Behav 2022; 52(2):231-243.. It was previously proposed that the suicidal narrative and SCS have a reciprocally aggravating effect on one another, culminating in suicide²³23 Cohen LJ, Gorman B, Briggs J, Jeon ME, Ginsburg T, Galynker I. The suicidal narrative and its relationship to the suicide crisis syndrome and recent suicidal behavior. Suicide Life Threat Behav 2019; 49(2):413-422..

Thus, this study aimed to examine differences in suicidal narrative and SCS symptoms, and suicidal ideation among those who maintained, lost, and gained employment or educational status during the COVID-19 pandemic in Brazil. In addition, we compared symptoms of narrative suicidal, suicide crisis syndrome, and suicidal ideation between workers and the unemployed. We hypothesized that (1) individuals who lost their jobs or educational status would have more elevated symptoms of the suicidal narrative and SCS when compared to those who maintained this status; (2) changes in occupational status during the COVID-19 pandemic would have mental health implications that would influence suicidal ideation.

Methods

Survey procedure

This is an online cross-sectional study on occupational status changes due to the implementation of the COVID-19 pandemic. This study was secondary data analysis of the International Suicide Prevention Assessment Research for COVID-19 (ISPARC) collaboration²⁵25 Rogers ML, McMullen L, Liang Y, Perez N, Richards JA, Akülker G, Barzilay S, Bilici R, Blum Y, Chistopolskaya K, Dudeck M, Husain MI, Kusmirek O, Luiz JM, Menon V, Pilecka B, Sadovnichaya V, Titze L, Valvassori SS, You S, Galynker I. Cross-national presence and sociodemographic correlates of the suicide crisis syndrome. J Affect Disord 2023; 329:1-8.. Participants completed this study anonymously using Qualtrics, a web interface. The survey link was available online for eleven months, from November 2020 to October 2021. Recruitment occurred via advertisements with links to the survey on social media (i.e., Facebook, Instagram, WhatsApp, and e-mail list to universities). Men and women over 18 years old, able to complete the consent form and complete the form with demographic information and self-report measures, were included. There were no specific exclusion criteria; however, adults who could not consent and children and adolescents were excluded (n = 81).

Our sample consisted of 2,259 individuals who were divided into groups: (1) those who maintained full-time (n = 844) part-time (n = 161) work or students (n = 1,153) both before and during the pandemic; (2) those who had full-time (n = 134) part-time (n = 108) work or students (n = 73) before the pandemic but who lost that employment/educational status during the pandemic; (3) those who did not have full-time (n = 95) part-time (n = 147) work, or students status (n = 122) before the pandemic, but who gained that employment/educational status during the pandemic; and (4) those who are not workers or who were unemployed both before and during the pandemic (n = 129). The same individual could work (full-time/part-time) and/or study.

Measures evaluated

Occupational status and demographic information

Sociodemographic information was collected before individuals completed the self-report measures. This information included questions about age, gender, region of residence, educational attainment, marital status, and a positive test for COVID-19 (Table 1). Changes in occupational status were investigated based on current employment/ educational status (at the time of the survey) and before the implementation of the COVID-19 pandemic. For this, the participants answered: “What was your occupation before your state was affected by the COVID-19 pandemic?” and “What is your current occupation?” The participants could respond to these two questions, selecting options such as unemployed, students, full-time homemaker, volunteer work, part-time work, full-time work, and retired (Table 2).

For assessments of the constructs of suicidal narrative and suicide crisis syndrome, we use the following scales: The Suicidal Narrative Inventory (SNI) assesses the suicidal narrative, a coherent cognitive structure in which the self-representation becomes sufficiently distressing that suicide becomes a viable option [20]. The Suicide Crisis Inventory-2 (SCI-2) asses the symptoms of suicide crisis syndrome, a negative mental state associated with suicidal thoughts and behaviors²⁰20 Cohen LJ, Ardalan F, Yaseen Z, Galynker I. Suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav 2018; 48(5):613-623.^,2323 Cohen LJ, Gorman B, Briggs J, Jeon ME, Ginsburg T, Galynker I. The suicidal narrative and its relationship to the suicide crisis syndrome and recent suicidal behavior. Suicide Life Threat Behav 2019; 49(2):413-422..

Abbreviated Suicidal Narrative Inventory (SNI)

The Abbreviated SNI measures the six components of the suicidal narrative utilizing a 5-point Likert scale ranging from 1 (not at all true) to 5 (extremely true)23. The abbreviated SNI includes 38 items grouped into subscales: perceived burdensomeness, thwarted belongingness, social defeat, humiliation, goal disengagement, and goal re-engagement. In this study, the total score of the SNI was used in all analyses. How suicidal narrative combine factors gathered from other theories of suicide (e.g., the interpersonal theory and the integrated motivational-volitional theory) that itself has not yet been empirically tested [20], also analysis was performed of all subscales of suicidal narrative (Table 3).

Suicide Crisis Inventory-2 (SCI-2)

The SCI-2 is a 61-item self-report questionnaire that assesses the presence of the symptoms of Suicide Crisis Syndrome (SCS). Items are rated on a 5-point Likert scale ranging from 1 (not at all true) to 5 (extremely true) in five subscales: The scale comprises five subscales: entrapment, affective disorder, loss of cognitive control, hyperarousal, and social withdrawal [26]. The SCI-2 total score was used in all analyses.

Columbia - Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a semi-structured interview considered the gold standard that measures the severity of suicidal phenomena [27]. In the self-report screener version, a rating scale of 0 to 5 measures the severity of suicidal ideation, ranging from death ideations, suicidal ideations, consideration of a method, suicidal intent, and the presence of suicidal ideation with a plan and intentions to act on this plan. In the present study, for descriptive data, individuals who reported scores greater than 2 were considered to have current suicidal ideation. Additionally, the C-SSRS total score was used to analyze the comparison differences of the changes in occupational status. Thus, suicidal ideation ranged from the passive wish to die to an action plan.

Data analysis

The database used the IBM Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp., 2012). A descriptive analysis of the variables was performed with measures of the frequency and percentage for categorical variables and the mean and standard deviation for quantitative variables. The Shapiro-Wilk test was used to assess the distribution of all variables regarding normality. For the evaluation of changes in occupational status (before and after the COVID-19 pandemic), the McNemar test was used. The differences in SCI-2, SNI, and C-SSRS scores were compared across the groups (changes in occupational status) with a Kruskal-Wallis H test, followed by Dunn’s post hoc test, when significant. Missing data were minimal and handled via listwise deletion after application of Little’s MCAR Test χ² =156,431 DF = 2, p < 0.001. All inferential analyses were performed with a significance level of α = 0.05.

Risk

The main risk of this study concerns individuals who could experience psychological discomfort during data collection. Therefore, to assure the safety of participants, national and local resources for suicide were provided in the information sheet at the beginning and end of the study. Particularly, contact and link to the program of the Centro de Valorização da Vida (CVV) and the Núcleo de Prevenção às Violências e Promoção da Saúde (NUPREVISPS) were presented.

Ethical issues

The Research Ethics Committee approved this study from UNESC (Universidade do Extremo Sul Catarinense) number 4.275.326. Participation in the research was voluntary, and there was no remuneration.

Results

A total sample included 2259 participants whose mean age was 31.14 years (SD = 10.94), 70.2% (n = 1,592) were female, 42.2% (n = 934) lived in the Southern, 35.7% (n = 789) in the Southeast, 13.3% (n = 294) in the Northeast, 6.4% (n = 141) in the Midwest, and 2.5% (n = 55) in the North regions of Brazil. The educational level of survey respondents was 35.4% (n = 803) graduation in progress, 29.3% (n = 661) bachelor’s degree, and 20.1% (n = 469) a master’s degree. Regarding marital status, 38.9% (n = 872) were single, 23.7% (n = 539) were married, and 20.8% (n = 461) were dating. Only 3.54 % (n = 80) of all participants have been diagnosed with COVID-19. According to C-SSRS, 10.93 % (n = 247) had suicidal ideation. Regarding suicide attempts, 12.57% (n = 283) of participants tried to kill themselves in their lifetime, and 1.32 (n = 30) of these were in the last month (Table 1).

The mean of the SNI total was 111.42 (SD = 18.00), the SCI-2 total was 160.05 (SD = 58.65), and the C-SSRS score total was 2.40 (SD = 1.45). In addition, Cronbach’s alpha was calculated to evaluate our sample’s consistency. The results showed that SNI and SCI-2 achieved excellent internal consistency in our sample (Cronbach’s alpha SNI was 0.85, and SCI-2 was 0.99) (Table 4).

Table 2 shows the occupational status of the participants before and during the implementation of COVID-19 in Brazil. According to the McNemar test, there was a change in sample proportion of unemployment (χ²(1) = 14.124; p < 0.001), of students (χ²(1) = 11.815; p < 0.001), of full-time homemaker (χ²(1) = 35.864; p < 0.001), part-time work (χ²(1) = 5.663; p = 0.017), retired (χ²(1) 8.100; p = 0.002) in full-time work (χ²(1) = 6.306; p = 0.012), before and during of the COVID-19 pandemic.

Table 5 shows the effects of changes in occupational status before and during the COVID-19 pandemic on the total SNI, SCI-2, and C-SSRS scores. According to the results of the Kruskal-Wallis H test, the group of individuals with full-time work showed statistical differences in the SNI total score when compared to the occupational status of the participants (χ² (3) = 97.37; p < 0.001). Pairwise comparisons demonstrated that the total score from SNI was higher in those who lost than in those who maintained their jobs (p < 0.001). In addition, the unemployed participants had an SNI total score higher than those who maintained, lost, or gained their work (p < 0.001). The Kruskal-Wallis H test also revealed differences in the SNI when comparing their occupational status in the individuals with part-time work (χ² (3) =28.45; p < 0.001), being that pairwise comparisons showed that the unemployed had a high SNI total score than those who maintained (p < 0.001), lost (p = 0.003), or gained (p < 0.001) their work. However, the occupational status did not significantly change the SNI score in the group of students.

The Kruskal-Wallis H test also demonstrated that the SCI-2 total score changes according to occupational status in the full-time work group (χ² (3) = 78.98; p < 0.001), and the unemployed individuals showed an elevated SCI-2 total score than those who maintained (p < 0.001), lost (p = 0.006), or gained (p < 0.001) their work. It is important to point out that participants who lost their job had an SCI-2 higher than those who maintained their positions (p < 0.001). The group with part-time workers also demonstrated differences in the SCI-2, according to the Kruskal-Wallis H test (χ² (3) = 20.33; p < 0.001). Pairwise comparisons found that those unemployed had SCI-2 higher than those who maintained (p < 0.001), lost (p = 0.040), or gained (p = 0.001) work. However, there were no statistical differences between occupational status on the SNI score in the group of students.

However, there were no statistically significant differences between changes in occupation status for full-time work, part-time work, and student groups on C-SSRS total score.

Discussion

The main purpose of this study was to assess the effects of changes in occupation status on suicidal narrative and suicide crisis syndrome (SCS) symptoms, and suicidal ideation. Our results showed that during the COVID-19 pandemic, there was an increase in unemployment, students, homemakers, part-time workers, and retired, as well as a decrease in full-time workers among the sample assessed. Our findings also showed that the changes in occupational status influenced suicidal narrative and SCS symptoms, but not suicidal ideation. In particular, individuals who lost full-time work have high SCS symptoms compared to those who maintained full-time work. On the other hand, no significant difference between those who gained and those who maintained employment on suicidal narrative and SCS symptoms. Similarly, no significant differences among all changes in educational status on suicidal narrative and SCS symptoms and suicidal narrative. In addition, the unemployed had higher symptoms of the suicidal narrative and SCS than workers.

Previous studies showed that changes in occupation are related to changes in physical and mental health²⁸28 Fujishiro K, Xu J, Gong F. What does "occupation" represent as an indicator of socioeconomic status? Exploring occupational prestige and health. Soc Sci Med 2010; 71(12):2100-2107.

29 Halleröd B, Gustafsson J-E. A longitudinal analysis of the relationship between changes in socio-economic status and changes in health. Soc Sci Med 2011; 72(1):116-123.^-3030 Lopes B, Kamau C, Jaspal R. The roles of socioeconomic status, occupational health and job rank on the epidemiology of different psychiatric symptoms in a sample of UK workers. Community Ment Health J 2019; 55(2):336-349.. Indeed, we found here that the individuals who maintained full-time work had fewer symptoms of the suicidal narrative and SCS than those who lost full-time work. Similarly, Marck et al. report that employment loss was prospectively associated with poorer mental health³¹31 Marck CH, Aitken Z, Simpson S Jr, Weiland TJ, Kavanagh A, Jelinek GA. Predictors of change in employment status and associations with quality of life: a prospective international study of people with multiple sclerosis. J Occup Rehabil 2020; 30(1):105-114.. Also, temporary employment was significantly associated with persistent suicidal ideation but not with newly developed suicidal ideation³²32 Sasaki N, Tabuchi T, Okubo R, Ishimaru T, Kataoka M, Nishi D. Temporary employment and suicidal ideation in COVID-19 pandemic in Japan: a cross-sectional nationwide survey. J Occup Health 2022; 64(1):e12319.. This can be explained by the relationship between loss of employment and the decrease in income³³33 Kiernan FM. Income loss and the mental health of young mothers: evidence from the recession in Ireland. J Ment Health Policy Econ 2019; 22(4):131-149.. Financial strain can lead to depression, anxiety, poor mental health, shame, and guilt in high-status groups³³33 Kiernan FM. Income loss and the mental health of young mothers: evidence from the recession in Ireland. J Ment Health Policy Econ 2019; 22(4):131-149.

34 Davalos ME, French MT. This recession is wearing me out! Health-related quality of life and economic downturns. J Ment Health Policy Econ 2011; 14(2):61-72.^-3535 Córdoba-Doña JA, Escolar-Pujolar A, San Sebastián M, Gustafsson PE. How are the employed and unemployed affected by the economic crisis in Spain? Educational inequalities, life conditions and mental health in a context of high unemployment. BMC Public Health 2016; 16:267.. We suggest that people who have lost full-time work may need additional mental health assessment and support during economic change, including future pandemics³⁶36 Yao R, Wu W. Mental disorders associated with COVID-19 related unemployment. Appl Res Qual Life 2022; 17(2):949-970..

Changes in occupational status in the part-time work group did not demonstrate significant differences in the suicidal narrative, SCS symptoms, and suicidal ideation. In addition, it is important to note that the number of individuals in the part-time work group increased. We found no other studies that evaluate the impact of part-time work changes (lost, gain) on mental health outcomes. However, Owens et al. showed that loss of part-time work predicted food insecurity³⁷37 Owens MR, Brito-Silva F, Kirkland T, Moore CE, Davis KE, Patterson MA, Miketinas DC, Tucker WJ. Prevalence and social determinants of food insecurity among college students during the COVID-19 pandemic. Nutrients 2020; 12(9):2515.. On the other hand, when compared to full-time work, nonstandard work (part-time work, temporary work, and daily work) was associated with depression/suicidal ideation for women and suicidal ideation for men³⁸38 Kim I-H, Muntaner C, Khang Y-H, Paek D, Cho S-I. The relationship between nonstandard working and mental health in a representative sample of the South Korean population. Soc Sci Med 2006; 63(3):566-574.. Additionally, part-time workers reported the greatest rates of fair/poor health³⁹39 Donnelly R, Schoenbachler A. Part-time work and health in the United States: the role of state policies. SSM Popul Health 2021; 15:100891.. In the present study, it is possible part-time work was not the only source of income for these individuals; that way, it could not affect their mental health.

Compared to the unemployed, the results of the present study showed that both the full-time and part-time workers had fewer symptoms of suicidal narrative and suicide crisis syndrome. This is in line with a cohort study that found that workers had a lower risk of urgent and involuntary psychiatric hospitalization when compared to the undeployed¹⁵15 Castelpietra G, Balestrieri M, Bovenzi M. Occupational status and hospitalisation for mental disorders: findings from Friuli Venezia Giulia region, Italy, 2008-2017. Int J Psychiatry Clin Pract 2019; 23(4):265-272.. Similarly, part-time employment was associated with lower levels of depression compared to unemployment⁴⁰40 Chiu C-Y, Chan F, Edward Sharp S, Dutta A, Hartman E, Bezyak J. Employment as a health promotion intervention for persons with multiple sclerosis. Work 2015; 52(4):749-756.. In addition, the unemployed had lower quality of life and mental health and a higher risk of suicidal ideation than employed individuals⁴¹41 Kwak Y, Kim Y. Health-related quality of life and mental health of elderly by occupational status. Iran J Public Health 2017; 46(8):1028-1037.. However, unemployment and insecure employment may be risks to mental health. For instance, Yoon et al. showed that individuals who became precarious part-time workers were more likely to have suicidal ideation than those who remained permanent workers⁴²42 Yoon S, Kim JY, Park J, Kim S-S. Loss of permanent employment and its association with suicidal ideation: a cohort study in South Korea. Scand J Work Environ Health 2017; 43(5):457-464.. At this point, our findings replicate data from the literature on unemployment as one of the predictive factors of poor mental health.

The data from the present study showed that the educational status changes were not statistically significant in suicidal narrative and SCS symptoms. We also found no studies that examined the impact of educational status changes on students’ health. To our knowledge, this is the first study to show this issue. However, college students may experience various mental health problems associated with their individual, study, and social experiences⁴³43 Lei X, Liu C, Jiang H. Mental health of college students and associated factors in Hubei of China. PLoS One 2021; 16(7):e0254183.. In contrast, higher education students had lower average psychological distress than those who did not⁴⁴44 Tabor E, Patalay P, Bann D. Mental health in higher education students and non-students: evidence from a nationally representative panel study. Soc Psychiatry Psychiatr Epidemiol 2021; 56(5):879-882.. It can partly be explained by higher education students’ better socioeconomic conditions⁴⁵45 Montez JK, Friedman EM. Educational attainment and adult health: under what conditions is the association causal? Soc Sci Med 2015; 127:1-7.. Also, young people with pre-existing mental disorders are less likely to attend higher education⁴⁶46 Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, Hwang I, Kessler RC, Liu H, Mortier P, Nock MK, Pinder-Amaker S, Sampson NA, Aguilar-Gaxiola S, Al-Hamzawi A, Andrade LH, Benjet C, Caldas-de-Almeida JM, Demyttenaere K, Florescu S, de Girolamo G, Gureje O, Haro JM, Karam EG, Kiejna A, Kovess-Masfety V, Lee S, McGrath JJ, O'Neill S, Pennell BE, Scott K, Ten Have M, Torres Y, Zaslavsky AM, Zarkov Z, Bruffaerts R. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Psychol Med 2016; 46(14):2955-2970..

Despite suicidal narrative and SCS demonstrating important differences between occupational status, the suicidal ideation among workers, unemployed, or students did not alter by changes in occupational status. Recently, SCI total had a significant positive relationship with suicidal behavior⁴⁷47 Flint J, Cohen L, Nath D, Habib Z, Guo X, Galynker I, Calati R. The association between the suicide crisis syndrome and suicidal behaviors: the moderating role of personality traits. Eur Psychiatry 2021; 64(1):e63.. Thus, SCS was proposed as an alternative method of detecting suicide risk²¹21 Schuck A, Calati R, Barzilay S, Bloch-Elkouby S, Galynker I. Suicide Crisis Syndrome: a review of supporting evidence for a new suicide-specific diagnosis. Behav Sci Law 2019; 37(3):223-239.^,2626 Bloch-Elkouby S, Barzilay S, Gorman BS, Lawrence OC, Rogers ML, Richards J, Cohen LJ, Johnson BN, Galynker I. The revised suicide crisis inventory (SCI-2): validation and assessment of prospective suicidal outcomes at one month follow-up. J Affect Disord 2021; 295:1280-1291.^,4848 Voros V, Tenyi T, Nagy A, Fekete S, Osvath P. Crisis concept re-loaded? The recently described suicide-specific syndromes may help to better understand suicidal behavior and assess imminent suicide risk more effectively. Front Psychiatry 2021; 12:598923.. Indeed, the combination of both SCS and suicidal ideation was associated with higher rates of suicide attempts during the one-month follow-up period⁴⁹49 Rogers ML, Bafna A, Galynker I. Comparative clinical utility of screening for Suicide Crisis Syndrome versus suicidal ideation in relation to suicidal ideation and attempts at one-month follow-up. Suicide Life Threat Behav 2022; 52(5):866-875.. Therefore, together SCS and suicidal ideation are more informative in identifying who may be at risk for engaging in suicidal behavior⁴⁹49 Rogers ML, Bafna A, Galynker I. Comparative clinical utility of screening for Suicide Crisis Syndrome versus suicidal ideation in relation to suicidal ideation and attempts at one-month follow-up. Suicide Life Threat Behav 2022; 52(5):866-875.^,5050 Rogers ML, Bloch-Elkouby S, Galynker I. Differential disclosure of suicidal intent to clinicians versus researchers: associations with concurrent suicide crisis syndrome and prospective suicidal ideation and attempts. Psychiatry Res 2022; 312:114522.. The suggestion for the results found here is that suicidal ideation is a more extreme outcome; nonetheless, the changes in employment status may lead to subtle mental health changes, which, combined with other risk factors, may lead to suicidal phenomena⁵¹51 Klonsky ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol 2016; 12(1):307-330.^,5252 Parker G. Do changes in employment status induce or "harvest" suicides? J Nerv Ment Dis 2019; 207(12):1039-1044.. Corroborating this hypothesis, suicidal ideation was associated with employees with pre-existing mental health conditions⁵³53 Sasaki N, Kuroda R, Tsuno K, Imamura K, Kawakami N. Increased suicidal ideation in the COVID-19 pandemic: an employee cohort in Japan. BJPsych Open 2021; 7(6):e199.. We understand that the individuals evaluated here were part of a heterogeneous group of the Brazilian community. Thus, the lack of suicidal ideation alteration according to the changes in occupational status could be explained by suicidal ideation being a less common occurrence for non-psychiatric individuals⁵⁴54 Rasouli N, Malakouti SK, Rezaeian M, Saberi SM, Nojomi M, De Leo D, Ramezani-Farani A. Risk factors of suicide death based on psychological autopsy method; a case-control study. Archives Acad Emer Med 2019; 7(1):e50.^,5555 Klonsky ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol 2016; 12(1):307-330..

Overall, it is generally accepted that the COVID-19 pandemic disproportionately affected the population⁵⁶56 Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med 2020; 8(6):547-548.. Families with economic difficulties and work changes experienced modifications in parent-child relationship dynamics that influenced emotional well-being⁵⁷57 Martin MA, Lennon RP, Smith RA, Myrick JG, Small ML, Van Scoy LJ; Data4Action Research Group. Essential and non-essential US workers' health behaviors during the COVID-19 pandemic. Prev Med Rep 2022; 29:101889.. A meta-analysis found no evidence that the blocks reduced positive psychological functioning, such as well-being, life satisfaction, or well-being⁵⁸58 Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med 2021; 51(2):201-211.. The innate capacity for psychological resilience, combined with feelings of support through texting, social media, and video conferencing, may have been a critical factor in the small effect of lockdown on mental health symptoms⁵⁹59 Williams CYK, Townson AT, Kapur M, Ferreira AF, Nunn R, Galante J, Phillips V, Gentry S, Usher-Smith JA. Interventions to reduce social isolation and loneliness during COVID-19 physical distancing measures: a rapid systematic review. PLoS One 2021; 16(2):e024713..

Several limitations are considered in this study: (1) the evaluation was based on self-report online, implying various forms of bias per se; (2) the cross-sectional nature of the analysis limited retrospective information; (3) since the occupation category of the participants was not differentiated, we were prevented from performing more detailed tests of worker status; (4) this study specifically examined the effects of changes in occupational status without considering factors that could influence the outcome of suicidal ideation; (5) the psychiatric history of the participants was not investigated; (6) although the research was open, the sampling technique adopted here enhanced the participation of university students; thus, the external validity of our results may be limited to the changes in an occupation that occur in the university environment; (7) the sample size of the occupational status change groups is unequal. Although the literature is inconclusive, the power to detect significant effects may be limited.

While further research is needed to confirm the generalizability of our results, our data suggest that changes in occupational status during the COVID-19 pandemic influenced symptoms of the suicidal narrative and suicide crisis syndrome, specifically in full-time work. Therefore, primary healthcare professionals would do well to consider changes in occupational status as a mental health risk factor during pandemics.

Acknowledgments

The authors would like to thank all the participants and research assistants who contributed to data collection and entry.

References

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