Study suggests disability test link to suicide risk

Behind the Headlines

Tuesday November 17 2015

It can be hard to prove cause and effect in the complex field of mental health

Suicide is a leading cause of death in middle-aged men

"Fitness to work tests linked to 590 extra suicides in England," warns the Daily Mirror. The paper reports a "horrific death toll" from the policy of reassessing disability benefit claimants. But there is reason to be cautious about whether the suicides were directly linked to Work Capability Assessments (WCAs).

WCAs, introduced in 2010, are intended to assess what work, if any, people are fit to do. People found to be fit for work are moved off disability benefit and expected to look for a job.

Researchers used data about the changing numbers of suicides, reported mental health problems, and prescriptions of antidepressants in 149 local authority areas in England. These were then compared with the numbers of people living in those areas who had undergone WCAs.

The main reported findings were that for every 10,000 WCAs in an area:

  • there were an estimated six extra suicides
  • there were 2,700 extra cases of reported mental health problems
  • GPs prescribed an extra 7,020 antidepressants

It cannot be assumed the WCAs were the direct cause of the increases in mental health problems seen in the study, which only compared rates per area.

This means we do not know whether the people who took their own lives or reported mental health problems had actually been through a WCA. Though, to be fair to the researchers, the government didn't release the data that would make such an analysis possible.

If you are troubled by persistent low mood, contact your GP. If you are thinking about suicide, you should phone Samaritans' free 24-hour helpline on 116 123. 

Where did the story come from?

The study was carried out by researchers from the University of Liverpool and the University of Oxford. It was funded by grants from the National Institute of Health Research, the Commission of the European Communities, and the Wellcome Trust.

The study was published in the peer-reviewed Journal of Epidemiology and Community Health on an open access basis, so it is available to read free online.

The tone of the media coverage differed, as you would expect with a story with such strong political overtones.

The Mail Online reported the study's findings in detail, but gave prominence to the Department for Work and Pensions' (DWP) description of the research as "wholly misleading", while the Daily Mirror used stronger, more emotive language, calling the extra suicides linked to assessments a "horrific death toll" and only including the DWP's statement at the very end of its report.

BBC News, The Guardian and The Independent gave more balanced coverage.

Buzzfeed News was the only news source to make the point that many of the limitations of the study were down to the DWP refusing to release more precise data on people who underwent a WCA.  

What kind of research was this?

This was an observational study, which looked at population-level data over time to see whether changes in rates of Work Capability Assessments (WCAs) were associated with rates of mental health problems. These types of observational studies can find links between factors, but cannot definitively prove that one causes another.  

What did the research involve?

Researchers collected information about mental health outcomes from 149 local authorities in England between 2004 and 2013. They looked to see how this was associated with the numbers of WCAs carried out in the different local authorities between 2010 and 2013. They adjusted their figures to take account of other factors that could have affected mental health outcomes.

The mental health outcomes studied were numbers of suicides – including deaths from injury of undetermined cause, sometimes used by coroners when it is unclear whether someone intended suicide – as well as the number of people reporting mental health problems in surveys and the number of antidepressant prescriptions written by GPs. 

For each outcome, the researchers calculated the rate per 100,000 people, looking only at adults aged 18 to 65 (those of working age who might be affected by WCAs).

Local authorities introduced WCAs at different rates, dependent partly on the number of people in an area receiving disability benefits and the number of staff available to start work. 

The researchers looked at how many people in an area had been through a WCA per 10,000 by the end of each quarter from 2010-13. They used these figures to look for links between WCAs and mental health outcomes.

Because more WCAs were carried out in deprived areas, the researchers adjusted their figures to take account of different deprivation, employment, wages and local authority spending levels, as well as looking at long-term trends in mental health conditions in individual areas.

They carried out a number of checks for other external factors that might influence results (confounders), including looking for links you would not expect to see, such as between WCA rates and mental health problems in adults over 65.

They also looked at whether the number of people with mental health problems increased before or after the number of WCAs in an area rose. All these tests were designed to make the results as reliable as possible.  

What were the basic results?

The study found rates of suicides, mental health problems and prescriptions of antidepressants were higher in areas that carried out more WCAs, after adjusting for baseline differences between areas. 

The researchers estimated for every 10,000 people reassessed, you would expect to see an additional six suicides (95% confidence interval [CI] 2 to 9), an extra 2,700 reports of mental health problems (95% CI 548 to 4,840) and 7,020 extra antidepressants prescriptions (95% CI 3,930 to 10,100).

Between 2010 and 2013 1.03 million people, or 80% of existing disability claimants, were reassessed using the WCA, equivalent to 3,010 per 10,000 of the population. 

During the study period the researchers calculated there were 590 additional suicides (5% of all suicides), 279,000 additional self-reported mental health problems (11% of total), and 725,000 more antidepressants prescribed (0.5% of total).

The extra tests designed to take other factors that might have affected the results into account did not find any evidence other factors were involved. 

How did the researchers interpret the results?

The researchers said this was the first analysis of the effects of the WCA policy on mental health, and the results indicate that, "It may have had substantial adverse consequences".

They say the process is potentially harmful and doctors should consider their involvement in implementing WCAs on ethical grounds.  

Conclusion

It is always hard to assess the direct impact of an intervention, outside the context of a randomised controlled trial. When the intervention is a social policy affecting thousands of people in very different circumstances around the country, the difficulty is that much greater.

The researchers did the best they could to guard against problems such as unexplained factors that might have affected the results, or reverse causality, where what looks like a result of an intervention is actually a cause of it.

Despite this, the study can only demonstrate associations between the data. We cannot say for sure that the WCAs were the direct cause of the mental health outcomes examined.

There is probably no way to tell this, even if you examined every single case of mental illness and suicide to find out whether the individual had been through a WCA and what the impact on them had been.

Mental health is complex, and influenced by various hereditary, health, personal and lifestyle factors. It is rarely possible to identify a single definite cause for suicide.

Population-level studies like this provide the best evidence we are likely to get about the potential effects of social policies, but they cannot provide firm answers.

It is important to keep the results in perspective. While the numbers of extra suicides (590) linked to WCAs sounds like a lot, this is an estimate. The researchers say the figure could be anywhere between 220 and 950, which is quite a wide margin of error. And the numbers who have undergone WCAs is much bigger – well over a million people.

We also cannot ignore the point that for many disabled people, regular employment can be empowering, not a burden. Disability needn't be an obstacle to working – there's a lot of guidance, support and training that can help you get back to work. Read more advice about disability and work.

If you, or someone close to you, is suffering from a mental health problem or thinking about suicide, it's vital to get help right away. There are many sources of support and good treatments for depression and anxiety, which can help people through difficult times.  

Analysis by Bazian. Edited by NHS Choices. Follow NHS Choices on TwitterJoin the Healthy Evidence forum.

Analysis by Bazian

Edited by NHS Choices

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Media last reviewed: 26/05/2015

Next review due: 26/05/2017

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