Research report

Evidence for the 2008 economic crisis exacerbating depression in Hong Kong
Sing Lee
a,b
, Wan-jun Guo
b,
, Adley Tsang
b
, Arthur D.P. Mak
c
, Justin Wu
d
,
King Lam Ng
a
, Kathleen Kwok
b
a
Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China
b
Hong Kong Mood Disorders Center, The Chinese University of Hong Kong, Hong Kong, China
c
Consultation Liaison Unit, Department of Psychiatry, Prince of Wales Hospital, Hong Kong, China
d
Institute of Digestive Disease, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
a r t i c l e i n f o a b s t r a c t
Article history:
Received 18 November 2009
Received in revised form 6 March 2010
Accepted 6 March 2010
Available online 8 April 2010
Background: There is a lack of population-level research on the relationship between economic
contraction and specic mental disorders and howindividual-level variables may mediate such
a relationship.
Methods: Two cross-sectional surveys using identical randomsampling and diagnostic methods
were conducted among Hong Kong adults in 2007 (JanuaryFebruary) and 2009 (AprilMay).
3016 and 2011 Chinese speaking adults completed structured interviews based on the criteria
of Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV).
Results: The twelve-month prevalence of DSM-IV major depressive episode (MDE) was
signicantly higher in 2009 (12.5%) than 2007 (8.5%). A signicant increase of prevalence was
found in both male and female respondents, those in the highest (5565 years) age group, having
secondary education level, were married/cohabited, divorced/widowed, employed, home-
making, and in the lowest and high-middle income groups. Those with large investment loss
had a signicantly higher prevalence of MDE (20.3%) than those with less or no-investment loss
(9.213.7%). The symptom pattern and severity of depression in 2007 and 2009 were similar.
Conclusion: Economic contraction triggered by a global nancial crisis was associated with a
signicant increase in the risk of depression in the Hong Kong population. This increase was not
explained primarily by unemployment and had a signicant contribution fromemployed, home-
making, high-middle income, and having married people. Aholistic perspective that encompasses
both ecological and individual levels of analysis is essential for studying the net impact of
economic contraction on depression across communities and sociodemographic groups and for
health policy planning.
2010 Elsevier B.V. All rights reserved.
Keywords:
Economic crisis
Depression
Mental health
Economic contraction
Major depressive episode (MDE)
Prevalence
1. Introduction
Interest in a link between economic contraction and mental
health is often heightened after major economic crises and has
led to many speculations that demand empirical examination
(Catalano, 2009; O'Dowd, 2009). Economic crises occur
unexpectedly and make it difcult for researchers to examine
them in a timely manner. Historically, governments might be
reluctant to support psychiatric epidemiological research
during economic crises because the ndings were politically
sensitive and might incite people to demand governmental
control of social stressors (Borowy, 2008; Catalano, 1991).
Some physical health indices (e.g., rates of obesity, coronary
heart disease, diabetes, stroke, and accidental injuries) could
improve during economic contraction because people might be
forcedby nancial reasons to adopt a healthier life style, suchas
by eating less meat and walking or cycling more (Borowy,
2008). By contrast, there is a lack of population-level research
on the relationship between economic contraction and specic
Journal of Affective Disorders 126 (2010) 125133
Corresponding author. 7A, Block E, Staff Quarters, Prince of Wales
Hospital, Shatin, N.T., Hong Kong, China. Tel.: +852 2144 7662; fax: +852
2144 5129.
E-mail address: guowjcn@163.com (W.J. Guo).
0165-0327/$ see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2010.03.007
Contents lists available at ScienceDirect
Journal of Affective Disorders
j our nal homepage: www. el sevi er. com/ l ocat e/ j ad
mental disorders and the role of individual-level variables that
might mediate the relationship (Catalano, 2009). This is true of
the Great Depression, oil shocks of the 1970s, the Asian crisis of
1997 and, most recently, the nancial tsunami of 2008. The
latter started in September 2008 with the declaration of
bankruptcy by the Lehman Brothers Holdings Inc. in the U.S.
and quickly globalized to bring about recession in nearly all
major economies.
Early studies on economic contraction and mental health
were based mainly on time trend analysis. Some of them
reported increased utilization of mental health services such
as higher admission rates of psychiatric patients (Borowy,
2008; Catalano, 1991; Weaver, 1983). However, society's
reduced tolerance of behavioral problems in a contracting
economy might lead to greater use of police power in
coercing patients into hospitalization. By contrast, reduction
of discretionary spending on medical care could decrease the
utilization of mental health service, especially in the early
phase of an economic crisis (Catalano, 2009). Therefore,
increased service utilization is weak evidence for economic
turmoil exacerbating common mental disorders.
More recent studies on the relationship between economic
contraction and mental health are of two main kinds. The rst
and more dominant type focused on job loss experienced at an
individual level of economic contraction. These studies found
that job loss was associated with depressive and anxiety
symptoms (Catalano et al., 2000; Mandal and Roe, 2008),
alcohol misuse (Catalano et al., 1993b; Khan et al., 2002),
suicide (Khanet al., 2008; Gunnell, 2009) andantisocial/violent
behavior (Catalano et al., 1993a). By measuring non-specic
psychological distress, they did not distinguish demoralization
from clinically signicant mental disorders (Catalano, 1991).
The other type of studies was ecological. They focused on
economic contraction experienced by the general population
and were based on repeated cross-sectional or longitudinal
design. They produced aggregate data, mostly using unem-
ployment rate as an indicator, that economic contraction had a
moderate exacerbating effect on suicide (Chang et al., 2009;
Gunnell, 2009) andantisocial/violent behaviors (Catalano et al.,
1999; Kessell et al., 2006), but diminished alcohol use and
related problems (Freeman, 1999; Ruhm and Black, 2002).
These two types of studies have several limitations that make
the net effect of economic contraction and policy alternatives on
mental health in a population hard to estimate. First, most
studies wereconductedinWesternpopulations, therebylimiting
their cross-cultural generalizability. For example, East Asian
societies are characterized by lowunemployment rates and high
personal savings. The latter is related to a strong sense of shame
associatedwithliving ondebt andpeople's practical needto save
up money in viewof weak welfare systems. The local experience
of global economic contraction and nancial insecurity may thus
be different (Catalano, 1991). Second, the associations found in
individual-level studies might arise from reverse causation, i.e.
pre-existing mental health problems bringing about job loss in
selected groups of individuals. Third, all individual-level studies
and most population-level studies had focused on job loss or
unemployment rate as the independent variable even though
the impact of economic contraction might involve complex
elements such as investment loss, reduced income, increased
workload and disrupted work and family relationships. Again,
these elements may vary across societies and economic crises.
The nal limitation is a general lack of empirical evidence from
repeated cross-sectional or longitudinal population surveys to
show that an economic crisis exacerbates a specic mental
disorder such as depression, a leading global contributor to the
burden of disease that is believed to increase in bad economic
times (Catalano, 2009; WHO, 2001). Instead, many studies used
non-specic symptoms, suicide and/or antisocial/violent behav-
ior as mental health outcome variables. The rate of suicide and
antisocial/violent behavior is, however, affected by many factors
that may not be connected with mental disorder per se. Suicide
has a lowand uctuant base rate and is associated with the most
severe forms of depressionthat occurredonly ina small subset of
depressed individuals. It may not even be connected with
depression at all (McCloskey et al., 2008; Lee and Kleinman,
2003). Likewise, those who remained employed during eco-
nomic contraction might be inhibited from displaying antisocial
behaviors because of the fear of layoff (Catalano et al., 1997,
Catalano, 2009). Since depression lies on a spectrum of severity
andis less likely to be inhibited, it shouldbe a more sensitive and
representative index of mental health.
As an open nancial center readily exposed to global
economic changes, Hong Kong was hit hard by the economic
crisis of 2008. There had been four consecutive quarters of
economic contraction. Unemployment rate increased modestly
from 4.4% in the rst quarter of 2007 to 5.3% in the second
quarter of 2009as actual layoffs occurredmostly inthe nancial
and other economy-sensitive sectors (Census and Statistics
Department, 2009a). However, what gripped people withgreat
fear was a marked drop in the value of their nancial
investments. The Hong Kong Dollar (HKD) has been pegged
at a rate of 7.8 HKD to 1 USD since October 17, 1983. It
subsequently exhibited the same fate of devaluation and low
interest rate as the USD, thereby forcing most people in Hong
Kong to avoiddepreciationof their assets by investing instocks,
high-interest currencies (especially the Australian Dollar), and
a range of other nancial products. Unfortunately, the Hang
Seng Stock Index fell drastically froma historical peak (31,897)
in October 2007 to 10,676 in October 2008 and uctuated at
levels lower than 16,000 till April 2009. Likewise, as nearly all
asset classes plungedinvalue, the AustralianDollar depreciated
by more than 35% relative to the HKD from July to November
2008. Consequently, the impact of investment loss following
the economic crisis was deep and widespread in Hong Kong.
The social impact of loss connected with the minibonds of
Lehman Brothers was particularly sensational and received
considerably more media coverage than news of layoffs. Seeing
that their lifelong savings had evaporated, thousands of retail
investors made up of ordinary citizens who held these
minibonds staged repeated public protests to demand the
government to take action on banks for mis-selling them as
low-risk products and to hold regulators responsible for having
failed to supervise banks and protect investors.
To examine the connection between the economic crisis
of 2008 (i.e., population-level economic contraction) and
depression in Hong Kong, we analyzed data from two general
population surveys on major depressive episode (MDE) con-
ducted in 2007 (January to February) and 2009 (April to May)
respectively. The rst survey was, expectedly, not conducted
with the economic crisis in 2008 in mind, but was designed to
examinebipolar depression(Leeet al., 2009a). Thesecondsurvey
was purposely designed to result in a repeated cross-sectional
126 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
study. Sincenon-specic psychological distress was commonand
might spontaneously remit following an economic crisis, the
second survey was conducted about 6 months after the onset of
the nancial turmoil when the more persistent impact of
economic contraction was likely to have surfaced. Given the
widespread impact of investment loss in the general public, we
included an individual-level item that asked about economic
contraction, namely, investment loss following the economic
crisis.
2. Methods
2.1. Sampling
Hong Kong has a population of 6.9 million and 99% of the
domestic households have a telephone at home (Census and
Statistics Department, 2009b), with very few of them having
more than one telephone line. Sampling telephone lines should
generate a representative sample of households. Both surveys
were approved by the Survey and Behavioral Research Ethics
Committee of The Chinese University of Hong Kong. The rst
interviewed respondents aged between 18 and 65 years and
was conducted between January 16 and February 16, 2007. The
second interviewed those between 15 and 65 years and was
performed between April 22 and May 13, 2009. By randomly
selectingtelephonenumbers fromthelocal telephonedirectory
withthe nal twodigits randomizedandmaking a maximumof
six attempts for each call, 7631 and 6387 potential respondents
respectively were courteously invited to participate in a survey
on emotional health and were assured of condentiality. All
of them gave verbal consent before a telephone interview
began. Responses were as follows: 3016 and 2011 successfully
completed, 1730 and 2585 hung up immediately, 1727 and
1062 rejected the interview; and for 1158 and 720 calls there
was no interviewee within the suitable age range. Therefore, of
the households that were successfully contacted and had
interviewees within the age range, the participation (or
cooperation) rate (Johnson and Owens, 2003) was 63.6%
(3016/[3016+1727] 100%) and 65.4% (2011/[2011+
1062] 100%) respectively. Both samples were weighted
according to the genderage distribution in Hong Kong and
had a representative genderage distribution comparable to
that of the general population as reported by the Census and
Statistics Department of the Hong Kong Government at the
end of 2006 (for 2007 sample) and 2008 (for 2009 sample).
With a 95% condence level, the maximum sampling errors
were 2.19% for both samples.
2.2. Instrument
The Cantonese Chinese survey instrument was devised by a
psychiatrist (S.L.) and a clinical psychologist (K.K.) specialized
in mood disorders in Chinese communities. Its items covered
sociodemographic correlates including gender, age, education-
al level, marital status, employment status, self-reported family
monthly income, symptoms of MDE in accordance with the
Diagnostic and Statistical Manual of Mental Disorders 4th
edition (DSM-IV) (American Psychiatric Association, 2000),
and level of distress and role functional impairment due to the
symptoms of MDE. The 2009 survey instrument asked
respondents to report the degree of investment loss according
to four categories (no investment, having investment with no
loss, small loss, and large loss).
Questions derived fromthe nine DSM-IVsymptoms of MDE
and allowing a dichotomous response were published else-
where (Lee et al., 2009a). Respondents who endorsed one or
both of the core MDE symptoms were asked whether seven
other associated symptoms of depression were present along
with the core symptom(s) most of the time, followed by the
questions on levels of distress and functional impairments
associated with the symptom(s) of MDE. Level of distress was
rated as none=0, mild=1, moderately severe=2, and
very severe=3. Impairment in four domains of role func-
tioning in the period when respondents reported the symp-
toms of MDE was assessed with the Sheehan Disability Scale
(Sheehan et al., 1996), which is widely used in both western
and Chinese community psychiatric surveys (Lee et al., 2009a;
Druss et al., 2009). The four domains include household
responsibilities (doing housework, such as cleaning and
grocery shopping), work/school (the ability to work, such as
working, studying, or taking exams), close relationships (the
ability to form and maintain close relationships with other
people, such as romantic partner, family members, or close
friends), and social life (the ability to form social relation-
ship), all of which were rated on a scale of 0 to 10 (none: 0,
mild: 13, moderate: 46, severe: 79 and very severe: 10).
In accordance with the DSM-IV, respondents were
classied as having twelve-month MDE if he/she 1) reported
ve or more symptoms, of which one must either be
persistently depressed mood or persistent loss of interest/
motivation, for at least two weeks in the previous twelve
months, and 2) very severe level of distress or severe
impairment in any of the four domains of role functioning
(i.e. scored 7 on any one of the four SDS domains). These
cutoffs of distress and impairment, according to a previous
concordance study in which 106 participants of the 2007
survey were re-assessed by clinical interviewers using the
Structured Clinical Interview for DSM-IV Axis I Disorder
(SCID-I), exhibited satisfactory AUC (area under the receiver
operator characteristic curve, 0.76), specicity (0.77), and
sensitivity (0.75) (Lee et al., in press).
Both surveys were conducted by an independently commis-
sioned survey research organization, the Hong Kong Institute of
Asia-Pacic Studies of The Chinese University of Hong Kong. The
interviewers were university students with 13 years of part-
time experience in administering telephone survey interviews,
including those about mental disorders. They were given a
brieng sessionto familiarize themselves withthe questions and
skills for eliciting the symptoms of depression. Onmost evenings
whenthe phone interviews were carriedout, one member of our
research teamrandomly monitored the phone interviewers and
provided feedbacks and clarication whenever necessary. Each
interview took an average of 20 min.
2.3. Statistical analysis
The statistical package SPSS 15.0 for windows was used.
The weighted MDE prevalence of the overall sample and that
of each sociodemographic category, frequency of each
symptom and average score of each type of severity mea-
surement (i.e. number of MDE symptoms, distress, and
impairment) among MDE cases were estimated for both
127 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
surveys using descriptive statistics. Scale data of severity
indicators were compared between 2007 and 2009 MDE
using t-tests. Chi-square test was used to compare categor-
ical data between the 2007 and 2009 surveys (prevalence
and symptoms of MDE) and among sociodemographic
groups (prevalence only). The risk (adjusted Odd Ratio:
aOR) for MDE of each sociodemographic group was esti-
mated using the backward conditional binary logistic
regression, in which the statistically signicant sociodemo-
graphic correlates of MDE in chi-square tests were used as
independent variables. The results of the above analyses
were evaluated based on an alpha level of 0.05 of a two-
tailed test.
3. Results
3.1. Prevalence of MDE
The twelve-month prevalence estimates of MDE for the
sample and those of each sociodemographic category in 2007
and 2009 were shown in Table 1. All estimates were higher in
2009 than in 2007. Statistically signicant elevations in 2009
were observed in overall respondents (both male and female),
the middle to high age group, those with secondary education
level, married/cohabited, divorced/widowed, employed, home-
makers, and in the lowest and the high-middle income groups.
Among these groups, the increased risk of MDE was most
marked in the divorced/widowed, highest aged (5565 years),
and high-middle income groups (OR=3.36, 3.02 and 2.53
respectively) (Table 1).
3.2. Sociodemographic correlates of MDE
The prevalence estimates of MDE were signicantly different
across most sociodemographic groups (except the age category
in 2009 and education category in both 2007 and 2009). When
controlling their compounding correlations, the prevalence
differences across age and education groups were no longer
statistically signicant. Generally speaking, the prevalence
estimates of MDE in both surveys were higher among
respondents who were divorced/widowed, unemployed, or
had lower family income. The high-middle income group had
the second highest prevalence of MDE (14.7%) among income
groups in 2009, unlike in the 2007 survey (6.4%) (Table 2).
Table 1
Weighted
a
sample composition ratios (%) and prevalence estimates (%) of MDE
b
in 2007 and 2009, and MDE risk estimate in 2009 vs. 2007 across
sociodemographic groups.
2007 (n=3016) 2009 (n=2011) Crude OR
c
(95%CI
d
)
for risk estimate in 2009
compared to that in 2007
Ratio Prevalence (95%CI
d
) Ratio Prevalence (95%CI
d
)
Overall 100.0 8.2(7.29.2) 100.0 12.5(11.013.9) 1.60
e
(1.331.93)
Gender
Male 46.9 6.7(5.48.0) 46.6 10.2(8.212.1) 1.57
e
(1.172.11)
Female 53.1 9.5(8.010.9) 53.4 14.5(12.416.6) 1.62
e
(1.282.06)
Age
1824 (1524 for 2009) 13.2 13.3(10.016.7) 17.0 14.0(12.416.6) 1.06(0.701.62)
2534 21.5 9.9(8.411.0) 20.4 14.3(11.116.4) 1.53
e
(1.052.24)
3544 25.5 7.4(5.89.1) 22.6 12.3(9.515.2) 1.76
e
(1.202.59)
4554 24.7 7.0(5.88.3) 24.2 10.6(8.412.8) 1.59(1.072.38)
5565 15.1 4.3(2.46.1) 15.8 11.6(8.015.1) 3.02
e
(1.705.36)
Educational status
Primary (grade 16) 12.6 8.7(5.911.6) 11.3 13.4(8.917.9) 1.60(0.952.71)
Secondary (grade 713) 53.9 7.1(5.98.4) 55.5 13.1(11.115.1) 1.96
e
(1.522.53)
Tertiary or above 33.5 9.7(7.911.5) 33.3 11.1(8.713.5) 1.16(0.841.59)
Marital status
Single 33.0 12.4(10.314.5) 38.4 13.6(11.216.0) 1.10(0.841.46)
Married/cohabited 62.8 5.6(4.56.7) 59.4 10.9(9.212.7) 2.10
e
(1.612.74)
Divorced/widowed 4.2 14.2(8.120.3) 2.1 36.0(21.350.7) 3.36
e
(1.517.52)
Employment status
Employed 67.0 7.4(6.28.5) 60.6 11.0(9.312.8) 1.55
e
(1.211.98)
Unemployed 5.0 14.6(8.920.3) 6.4 17.8(11.224.5) 1.27(0.672.41)
Full-time students 7.4 13.2(8.717.7) 12.1 15.7(11.320.0) 1.24(0.742.10)
Home-makers 13.6 8.8(6.611.0) 13.9 14.5(11.218.0) 1.78
e
(1.112.87)
Retired 7.1 4.7(1.87.5) 7.0 8.5(3.813.2) 1.89(0.804.52)
Family monthly income (HKD)
f
b$10,000 19.9 10.0(7.512. 6) 20.8 16.5(12.820.3) 1.78
e
(1.232.58)
$10,000$29,999 47.9 9.1(7. 610.7) 46.6 10.5(8.512.6) 1.16(0.881.53)
$30,000$59,999 22.3 6.4(4.58.4) 22.3 14.7(11.318.1) 2.53
e
(1.683.79)
$60,000 9.9 5.1(2.57.7) 10.3 8.1(4.212.0) 1.69(0.823.46)
a
Data were weighted according to gender and age distributions in Hong Kong.
b
Major Depressive Episode.
c
Odds ratio based on Chi-square tests.
d
95% condence intervals based on Chi-square tests.
e
MDE risk estimates were signicantly higher than those in 2007 (two-sided, p 0.05).
f
USD 1=HKD 7.8.
128 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
3.3. MDE prevalence by investment-loss category in 2009
There were 23.4%, 24.4%, 41.4% and 10.9% of respondents
who reported no investment, investment with no loss, small
loss and large loss respectively (Table 1). The prevalence of
MDE was signicantly different across investment-loss
groups (
2
=19.81, pb0.001). The highest prevalence of
MDE was observed in the large-loss group (20.3%) while the
lowest prevalence was observed in the small-loss group
(9.2%). Prevalence in the no-investment group (13.4%) and
the no-loss group (13.7%) was similar (Table 3). After
controlling the effect of sociodemographic correlates men-
tioned above, the comparison remained statistically signi-
cant. Moreover, the adjusted OR of the large-loss group was
signicantly higher than those of all other investment-loss
groups.
3.4. MDE symptom pattern in 2007 and 2009
The distributions of MDE symptoms varied between 53.1
93.8% and 40.592.2% among those with MDE in 2007 and
2009 respectively (Table 4). Of the nine DSM-IV symptoms of
MDE, only feeling worthless and suicidal ideation were
signicantly different in distribution between 2007 and
2009. Both symptoms were more common in 2007
(Table 4). Since MDE associated with these two symptoms
could be more relevant to suicidality, we compared the
prevalence of MDE presenting with one of these two
symptoms between 2007 and 2009. The prevalence estimates
of MDE with the symptoms of feeling worthless (8.3% vs.
6.5%) and suicidal ideation (5.0% vs. 4.3%) were higher in
2009 than 2007, but the differences were not statistically
signicant.
Table 2
Sociodemographic correlates of MDE
a
in Hong Kong in 2007 and 2009.
2007 (n=3016) 2009 (n=2011)
[
2
, p] based on
Chi-square test
Adjusted [
2
, p] and
OR(95%CI)
b
[
2
, p] based on
Chi-square test
Adjusted [
2
, p] and
OR(95%CI)
b
Gender [7.72, 0.005] [7.34, 0.007] [8.47, 0.004] [5.76, 0.016]
Male 0.68
c
(0.510.90) 0.68
c
(0.500.93)
Female 1 1
Age [27.94, b0.001] [3.86, 0.425]
Educational status [5.46, 0.065] [1.65, 0.438]
Marital status [44.65, b0.001] [42.43, b0.001] [18.35, b0.001] [19.30, b0.001]
Single 0.96
c
(0.541.71) 0.27
c
(0.130.56)
Married/cohabited 0.39
c
(0.220.68) 0.21
c
(0.100.42)
Divorced/widowed 1 1
Employment status [19.17, b0.001] [12.28, 0.015] [11.29, 0.024]
Employed 1.63(0.793.35)
Unemployed 3.04
c
(1.336.99)
Full-time students 2.48
c
(1.075.74)
Home-makers 2.19
c
(1.014.77)
Retired 1
Family monthly income (HKD)
d
[10.505, 0.015] [6.95, 0.073] [14.43, 0.002] [13.17, 0.004]
b$10,000 1.91
c
(1.033.54) 2.02
c
(1.073.83)
$10,000$29,999 1.63(0.922.90) 1.27(0.702.30)
$30,000$59,999 1.21(0.642.29) 2.10
c
(1.143.85)
$60,000 1 1
The categories not having adjusted odds ratio and [
2
, p] because they were not associated with MDE before or after controlling for the associated categories.
a
Major Depressive Episode.
b
Adjusted odds ratio and its 95% condence intervals based on regression analysis, in which only the statistically signicant sociodemographic correlates of
MDE in chi-square tests (including investment-loss groups in Table 3) were used as independent variables.
c
Adjusted odds ratios signicantly higher than those of the reference groups.
d
USD 1=HKD 7.8.
Table 3
Weighted
a
sample composition ratios (%) and MDE
b
prevalence estimates in 2009 by investment loss (n=2011).
Ratio Prevalence MDE
b
risk estimate among groups
c
% (95%CI
d
) Adjusted OR
e
(95%CI
d
)
No investment 23.4 13.4 (10.316.5) 0.47
f
(0.290.76)
No loss 24.4 13.7 (10.616.8) 0.54
f
(0.340.86)
Small loss 41.4 9.2 (7.311.2) 0.42
f
(0.280.65)
Large loss 10.9 20.3 (14.925.7) 1
a
Data were weighted according to gender and age distributions in Hong Kong.
b
Major Depressive Episode.
c
Crude
2
=19.81 (pb0.001) and adjusted
2
=16.29 (p=0.001) for testing among four groups.
d
95% Condence Intervals.
e
Adjusted odds ratio after controlling sociodemographic correlates in Table 2.
f
Adjusted odds ratios signicantly lower than that of the reference group (i.e., the large-loss group).
129 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
3.5. Severity of MDE in 2007 and 2009
There was no signicant difference in the number of MDE
symptoms, distress score, and average or domain-specic
scores of SDS between those with MDE in 2007 and 2009
(Table 4).
4. Discussion
4.1. Prevalence of depression
The present study is the rst of its kind to suggest a
signicant increase in the prevalence of a common and
clinically dened mental disorder (namely, DSM-IV major
depressive episode) in a general population experiencing
economic contraction triggered by a global nancial crisis. We
are not aware of epidemiological studies of the prevalence of
MDE conducted in other communities after the economic crisis
of 2008. The twelve-month prevalence of MDE we found in the
2009 survey was higher than previous surveys (Lee et al., 2007,
2009a). Since the diagnosis of depression was based on
standardized and clinically validated criteria, we excluded
subthreshold and non-specic psychological distress. Although
unexamined social factors might contribute to this elevated
prevalence, several lines of evidence would suggest that
economic contraction played a role in the new onset of
depression. First, the two surveys used an identical methodol-
ogy, standardized diagnostic denition of depression, and
representative general population samples. This rendered the
possibility of methodological and diagnostic bias across the two
surveys unlikely. Second, our rst survey of MDE in Hong Kong,
based on an identical methodology and conducted in 2005
(Lee et al., 2007), showed similar overall and gender-specic
prevalence estimates when compared to those of the 2007
survey (8.3%vs. 8.2%,
2
=0.05, p=0.819; males: 6.8% vs. 6.7%,

2
=0.01, p=0.941; females: 9.7% vs. 9.5%,
2
=0.04,
p=0.851). Unlike 2008 to 2009, the period between 2005
and 2007 in Hong Kong was marked by economic growth and
societal stability. The similar estimates in 2005 and 2007
indicated that MDE in Hong Kong was likely to be a stable
condition prior to the economic crisis. Third, the prevalence of
MDE among respondents with large investment loss was
signicantly higher than those of all other investment groups.
This individual-level association might arguably be due to the
phenomenon of reverse causation (Catalano, 1991), i.e., the
greater tendency of depressed than non-depressed respon-
dents to report the adverse economic experience of investment
loss. However, the relatively low prevalence of depression in
the small-loss group compared to the no-loss group among
those with MDE argued against this possibility. Finally, the
pattern of prevalence elevation across sociodemographic
groups pointed to the specic impacts of economic contraction
on depression. Thus, an association of the high-middle income
group with MDE was found in the 2009 but not 2007 and 2005
surveys. This group made up 22.3% of the respondents and was
larger thanthe entire groupof unemployed respondents (6.5%)
in 2009. Such a new correlate for MDE during the economic
downturn suggested that economic contraction did not
increase psychiatric morbidity by merely aggravating those
already pre-disposed to mental disorders (Borowy, 2008).
4.2. Groups at risk
The present study identied how the risk of a mental
disorder during economic contraction increased across broad
sociodemographic groups. Although we were not able to re-
interview the same respondents who took part in the 2007
survey for the 2009 survey, our ndings allowed a rough
estimate of the contribution of each sociodemographic group
to risk increase in the overall population. Previous studies
usually attributed the rise of mental health problems
(predominantly completed suicide and antisocial/violent
behavior) during economic contraction to the adverse impact
of job loss (Catalano, 1991, 2009; O'Dowd, 2009). We did not
assess job loss specically but job loss should have contrib-
uted to the overall increase in prevalence. This is because the
prevalence of MDE in the unemployed group did increase
from 2007(14.6%) to 2009 (17.8%), and was the highest
among employment subgroups in both surveys. However, the
contribution of the unemployed group and hence job loss to
risk increase in the overall sample was limited. Although
unemployment rate increased from 5.0% in the 2007 survey
to 6.4% in the 2009 survey, the proportion of the unemployed
group in the overall sample was small and the degree of OR
increase in this group was less than in the overall sample.
Factors other thanreal job loss during economic contraction
might thus make a greater contribution to the increase of MDE.
Among marital groups, the risk increase was most marked in
the divorced/widowed group. This conrmed that this conven-
tionally recognized risk group was more prone to the adverse
impact of economic contraction (Borowy, 2008). Nonetheless,
thosenot conventionally at riskwere alsoaffected. For example,
the risk increase (OR=2.10) in the married/cohabited group
Table 4
MDE
a
symptom prevalence and severity among 2007 and 2009 MDE
a
cases.
MDE
a
symptom
prevalence
2007 (n=246) 2009 (n=249)
% (95%CI
b
) % (95%CI
b
)
Depressed mood 82.7 (77.987.4) 84.4 (79.888.9)
Low motivation 82.6 (77.987.3) 84.2 (79.688.7)
Change in Weight
or appetite
77.1 (71.982.4) 82.0 (77.286.8)
Change in sleep 93.2 (90.196.4) 88.9 (85.092.8)
Psychomotor agitation
or retardation
74.6 (69.180.0) 73.7 (68.279.2)
Fatigue 86.0 (81.790.4) 91.2 (87.794.7)
Loss of concentration 93.8 (90.896.8) 92.2 (88.995.5)
Feeling worthless 79.7
c
(74.784.7) 66.7 (60.872.5)
Suicidal ideation 53.1
c
(46.859.3) 40.5 (34.446.6)
Severity of MDE
a
Mean (95%CI) Mean (95%CI)
Number of MDE
symptoms
7.23 (7.077.39) 7.03 (6.877.19)
Distress (03) 2.18 (2.082.28) 2.03 (1.932.13)
Role impairments (SDS
d
) (010)
Housework 5.22 (4.835.61) 5.17 (4.785.56)
Work 6.62 (6.296.95) 6.55 (6.226.88)
Close relationship 6.26 (5.976.55) 6.41 (6.106.72)
Social 5.97 (5.646.30) 5.82 (5.496.15)
Average 6.02 (5.786.26) 5.99 (5.776.20)
a
Major Depressive Episode.
b
95% Condence Interval.
c
Numbers signicantly higher than those of 2009.
d
SDS=Sheehan Disability Scale.
130 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
was not only statistically signicant, but was also higher thanin
the overall population (OR=1.60). Statistically, it was signif-
icantly higher than in the group of single respondents. This
might suggest that the effect of economic contraction on family
life contributed to risk increase of MDE in the general
population. Among employment groups, the signicantly
increased prevalence of MDE in the employed and home-
making groups might arise from restructuring of job routines,
increased workload, and decreased job security that in turn
threatened the nancial security of family life. This is unlike
substance misuse and antisocial behaviors which could
decrease among those who did not lose their jobs and feared
layoff during economic contraction (Catalano et al., 1997;
Catalano 2009). Among age groups, the elevation was more
marked among older respondents and most marked among
those in the highest age (5565 years old) group. This is
consistent with individual-level studies that, among older
adults, becoming unemployed was associated with signicant-
ly more distress and depression. More substantial nancial and
family responsibilities they had to bear could have contributed
(Mandal and Roe, 2008; Breslin and Mustard, 2003). In
addition, respondents in the 5565 years old group were
retired or approaching retirement. They might experience
morenancial insecurity about the future because of their more
limited opportunities for nancial reversal than younger
respondents. A nding that was especially relevant to invest-
ment loss was the most severe prevalence elevation of MDE in
the high-middle income group among all income groups. This
group included the second largest proportion (only smaller
than the highest-income group) of respondents who reported
large investment loss (detailed data on family income and
investment loss are available upon request). Given the lower
reserve of their assets, they could be less tolerant of nancial
insecurity than the highest-income group who typically
maintained a similar level of living despite nancial losses.
The fact that they were usually not entitled to government
welfare benets could render them particularly vulnerable to
the adverse impact of economic downturn.
4.3. Pattern and severity of depression
Besides the elevation of prevalence and new correlates of
depression in 2009, some other ndings are noteworthy.
First, the sociodemographic correlates of MDE in both surveys
were mostly consistent with published research. They
included higher prevalence among respondents with lower
socioeconomic status (Lorant et al., 2003; Wang et al., 2009),
unemployment (Lee et al., 2007, 2009b; Kessler et al., 2003),
disrupted marital status (Lee et al., 2009b; Kessler et al.,
2003) and lower income (Wang et al., 2009). These ndings
supported the general validity of our ndings. Second, the
pattern and number of symptoms of MDE, level of distress, and
severity/pattern of impairments were similar between respon-
dents withMDEin2007 and2009. Our study is the rst toshow
that economic contraction might increase the prevalence of
depression but the symptompattern and severity of depressive
episodes remained similar. This may suggest that established
interventions for depression are likely to work for those whose
illness was triggered by economic contraction. At present,
though, no study has addressed whether these individuals
would present differently in clinical settings or spontaneously
recover when economic recession is over. We also do not know
whether increasing treatment rate will necessarily reduce the
overall societal burden of depression connected with economic
contraction (Catalano et al., 1997; Catalano 2009). Third,
feelings of worthlessness and suicidal ideation were less
common among respondents with MDE in 2009 than 2007.
Further analysis showed that there was no signicant differ-
ence in the prevalence of MDE with these symptoms in the two
surveys. These ndings suggested that in communities that
demonstrated a signicant increase of suicide following
economic contraction, the pathway to suicide might be
mediated by mechanisms other than depression, such as
impulsivity (McCloskey et al. 2008), shame, hopelessness,
debt and other forms of psychosocial predicaments (Lee and
Kleinman, 2003). Fourth, some individual-level studies found
that job loss has a greater psychological impact on men than
women, probably via the loss of income, structured time, social
contact and status (Jahoda, 1982; Virtanen, 2008). If job loss is
taken to be the main pathway by which economic contraction
impacts on mental health, a greater elevation of MDE
prevalence should be expected in men than women. However,
we found that prevalence elevation was similar between men
andwomen. Froma holistic perspective of the complex impacts
of economic contraction, non-job related factors could thus
inuence the gender-specic prevalence of depression (Cata-
lano, 1991).
4.4. Limitations
Since population characteristics, cultural norms concerning
response to economic adversity and local impacts of economic
contraction may shape the economymental health relation-
ship across communities, our ndings may not generalize to
other societies. Moreover, depression could be but one of the
many possible outcomes of coping with the economic crisis.
Telephone-based psychiatric surveys have the advantages of
affordability, quick turnaround time, wide geographic coverage,
and good agreement with surveys using face-to-face interviews
in both clinical and general population samples (Evans et al.,
2004; Fenig et al., 1993; Rohde et al., 1997). Provided nearly all
households in a community have a telephone line, these
advantages make it especially suitable for the timely examina-
tion of changes connected with natural disasters and socioeco-
nomic crises (Bleichet al., 2003; Galea et al., 2007). Nonetheless,
since our telephone interviews were anonymous, we were
unable to re-interview the same respondents who took part in
the 2007 survey for the 2009 survey. Consequently, our samples
did not constitute a longitudinal cohort that allows analysis of
incidence and interactions of sociodemographic correlates to
clarify the pathways between economic contraction and
depression. In order to reduce refusal rate, a telephone-based
survey had to be relatively brief. We therefore left out detailed
clinical and sociodemographic issues such as comorbid mental
disorders, objective amounts of investment/income loss, wel-
fare status, and type of job displacement. The latter is especially
worth studying in details because recent layoff, plant closings,
long-term unemployment and voluntary withdrawal from
the labor market may have special meaning and risk effects
in Asian societies that are not used to high unemployment
rates and have limited welfare provisions. These issues could
have been covered during face-to-face interviews. We reported
131 S. Lee et al. / Journal of Affective Disorders 126 (2010) 125133
participation rates commonly used in telephone surveys
(Johnson and Owens, 2003) rather than strict response rates
(55% and 36% respectively) that included subjects who hung up
immediately for unknown and probably diverse reasons.
Previous research suggested that people with depression
might be more likely to refuse in-person survey interviews
(Eaton et al., 1992) than those without. If this is true of
telephone surveys conducted during bad economic times, the
lower response rate in the 2009 survey might result in a
conservative estimate of prevalence elevation. Finally, the
sample in the 2009 but not the 2007 survey included some
younger (1517 years old) respondents. Nonetheless, this slight
sampling difference did not contribute to the higher prevalence
estimate in 2009. Rather, the prevalence elevation in the
youngest groups was not signicant and their MDE was much
milder than in the overall sample. Consequently, inclusion of
this group of respondents in the 2009 survey might only have
led to a more conservative estimate of prevalence elevation and
did not change the main ndings of the present study.
4.5. Policy implications
Economic contraction usually resulted in reduced tax pay-
ments and cuts in health budgets at a time when people most
needed treatment and support (Borowy, 2008). Our ndings
would argue for strengthening mental health services during
economic contraction rather than across-the-board cuts in
health budgets for both mental and physical illnesses. These
services should cater to conventionally recognized groups at risk
as well as new risk groups whose treatment needs may not
otherwise be met. How this is to be done will differ across
communities (Catalano, 2009). In Hong Kong, the public mental
health service is nearly free but the average waiting time for a
new outpatient appointment is about a year. The service has
focusedonlow-income people withsevere mental disorders and
bears considerable stigma (Lee et al., 2006). Treatment is
predominantly pharmacological. Evidence-based psychological
treatment which may be especially relevant to depression
triggered by economic contraction barely exists. Even among
those individuals who have employer-provided or private
medical insurance, cover is only partial and often does not
include the treatment of mental disorders. To meet the needs of
the spectrum of groups at risk during economic contraction,
timely and user-friendly policies and programs will need to be
nanced and developed, especially for those with more serious
illnesses that demand clinical intervention. This is so because the
hope for a sustainable recovery of the real economy in 2010
remains controversial.
Role of funding source
This study did not receive any external funding.
Conict of interest
None declared.
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