Read and summarize each of the readings listed below, separately, in at least 3-4 sentences: ?After completing the readings, make sure to also provide something to substantiate th

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O

F I N A N C E A N D A S S E T S

The Burden of Debt on Mental and Physical Health AUGUST 2, 2018  • F I N A N C I A L S E C U R I T Y P R O G R A M &

D Y V O N N E B O D Y

n March 8, 2016, Jerome Rogers was found dead near his childhood

home in South London. Jerome, a 20-year-old courier, committed

suicide in response to the pressure of his mounting debt. In less than four

months, two unpaid traffic fines spiraled from £65 to over £1,000 — an amount well above his means to pay. After debt collectors began to

threaten Jerome with seizure of assets and additional charges, he

tragically chose to take his own life.

Although Jerome’s story is rare, the burden of debt on mental health is

not. In the US alone, individuals who struggle to pay off their debts and loans are more than twice as likely to experience mental health problems,

including depression and anxiety. Today’s unprecedented levels of

consumer debt prompt further exploration of its effect on mental and physical well-being.

Stress and Suicide

While suicide is not a common response to unmanageable debt, it remains a leading cause of death in the US. The potential of suicide

increases among financially distressed individuals as debt levels become

harder to manage. Suicide rates have increased by more than 30 percent since 1999 according to a recent report by the Center for Disease Control.

Like Jerome, more than half of people who die by suicide do not have a

history of depression or mental illness. Almost 30 percent of suicides

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occur in response to a crisis within the past two weeks and 16 percent

occur in response to a financial problem.

How Consumer Debt Affects Mental And Physical Health

Among individuals with consumer debt, those in financial distress, or

those who struggle to repay debts, are more likely to report lower life satisfaction and higher anxiety. Similarly, research published by the

National Institutes of Health (NIH) found that high debt-to-asset ratios are

also associated with higher perceived stress and depression. When looking

at young adults with student debt, those with high levels of debt stress reported feeling more tense and anxious, troubled by physical problems,

and having greater difficulty getting to sleep than students with low levels

of debt stress. Looking across multiple studies, a strong consensus emerges among researchers correlating debt and mental health. A 2010

meta-analysis of over 60 diverse papers confirmed a significant

relationship, with further links between debt and suicide completion, drug

and alcohol abuse, and health outcomes such as obesity.

16 percent of suicides in the US occur in response to a financial problem.

Individuals with significant debt are also more likely to report physical

health challenges, which are often closely associated with mental well-

being. The NIH find that individuals who believe they owe higher levels of debt have a 1.3 percent higher average diastolic blood pressure (DBP). Even

small increases in DBP are associated with a significantly higher risk of

hypertension and stroke. According to an Associated Press health poll,

approximately 10 to 16 million people in the US have reduced physical health due to high debts. For those with self-reported high debt stress, 27

percent had ulcers or digestive tract problems compared to 8 percent who

reported low debt stress. Similarly, 44 percent of those with high debt

stress had migraines or headaches compared to 15 percent of those with low debt stress (Figure 1).

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Figure 1. The toll owing money takes on the body

(Poll of 1,002 adult taken March 24-April 3, 2008: margin of error ± 2.31 percent)

Associated Press-AOL Health Poll, Debt Stress: The Toll Owing Money Takes on the Body, April 2008

Effect On Black Households

The correlation between mental health challenges and debt are even

stronger among black individuals, though this association has been the

subject of fewer studies. Black people are more likely to report higher

financial stress and greater debt levels than any other racial or ethnic group in the US. Wealth inequality among blacks and whites has widened

in the past two decades, leaving the average white family ten times

wealthier than the average black family. In 2016, white households had a median net worth of $171,000, while black households had a median net

worth of only $17,409 (see Figure 2).

Generations of discrimination have left black households with fewer

resources to draw upon when under financial pressure. Nearly 1 in 5 black

households have zero or negative net worth, where total debts exceed total assets. Since black individuals experience higher levels of

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financial stress and debt, the toll taken on the mental and physical well-

being of black individuals is likely high.

Figure 2. Median family wealth by race/ethnicity, 1963-2016

Gig Work And Income Volatility

Jerome’s profession as a self-employed courier may have only

compounded his situation. Many self-employed and gig workers

encounter high levels of monthly income volatility due to unstable work

conditions and erratic pay. Research finds that income volatility is positively associated with depression and dramatically increases the

likelihood of an individual having various forms of debt. Jerome’s

unpredictable income made it difficult for him to keep up with debt payments related to the two unpaid traffic fines. This resulted in rapidly

escalating late fees which ballooned the debt he already struggled to pay.

Conclusion

While it is easy to understand the impact of debt on financial well-being,

its impact on mental health remains less familiar. Even today, the

connection between consumer debt and mental health is virtually unknown and the measure of its impact remains underreported. The

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tremendous rise in consumer debt in the past decade poses a continuous

risk to the mental and physical well-being of Americans. Insights explored by Aspen EPIC highlight the need for increased studies of the consumer

debt burden and the need for better mental health practices for those

struggling with debt and other forms of financial distress.

R E L A T E D

F I N A N C E A N D A S S E T S

The Story Behind 16 Million Abandoned Retirement Savings Accounts

J U N E 6 , 2 0 1 8 • B E N W H I T E

PersPective https://doi.org/10.1038/s43587-021-00160-1

1Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Queensland, Australia. 2Slovenian Center for Suicide Research, Primorska University, Koper, Slovenia. ✉e-mail: [email protected]

Older people die by suicide at a disturbing rate. This sad phe- nomenon occurs more often in older men, particularly those over 80 years of age1, especially when facing conditions such

as chronic pain and dependence on others, but also when suffering from loneliness, feelings of abandonment and loss of meaning for life2. All these conditions are risk factors for suicide3; some of these factors can be controlled and their impact limited; some others may simply be too much of a burden on individuals and their families. Ageist attitudes associate old age with physical and cognitive decline (considering older adults to be frail and helpless individuals) and inevitably influence the level of care that these individuals receive4. Thus, opposing ageism (see definitions for key terms in Box 1) can significantly reduce the impact of the risk factors that contribute to suicidal behavior and reduce the number of fatal suicide attempts. Measures to prevent suicide attempts might also reduce suicide risk for others, as there is evidence that exposure to suicide within ones’ social group increases the risk of suicidal behavior5.

This article provides an overview of existing knowledge on sui- cide in old age and discusses it in the context of the global aging population, the increase in longevity around the world and the potential impact of the pandemic (Boxes 1, 2).

Global aging, longevity and suicide Suicide rates have declined globally, and quality of life and access to health care have improved. However, suicide rates of older people remain the highest worldwide1 (Fig. 1). In general, there is a progressive increase in suicide rates with age, especially among men6,7, and this trend may continue even among ultra-centenari- ans8. Globally, in 2017, suicide in old age affected 16.17 individuals per 100,000 inhabitants at the age of 50–69 years and 27.45 indi- viduals per 100,000 inhabitants at the age of 70 or more years1. With epidemiological data predicting an almost doubling of the older population in less than 30 years9 and the increasing proportion of mononuclear families, the concern of increased social isolation, loneliness and addiction, known risk factors for suicide10, does not appear unfounded.

Old age is a social concept rather than a true biological one11. In fact, there is no clearly defined and universally valid threshold that marks old age, as a person’s chronological age is not well linked to their physical and mental capabilities. While chronological age increases at the same rate for everyone everywhere, biological age depends on epigenetic alteration and DNA methylation and related bodily changes occurring in a given person12. The threshold for

entering old age is generally considered to be 65 years. However, especially in high-income countries, people aged 65–74 years gen- erally enjoy good health and continue to benefit from satisfactory levels of social inclusion and availability of resources as in younger age. In low- and middle-income countries, rather than chronologi- cal age, old age seems to be defined by cessation of active participa- tion in society13.

Literature relating to suicide in old age also generally considers 65 years as the threshold level; however, given the relative numerical rarity of the phenomenon, many investigations have also included younger individuals14. However, especially for a Western country, considering individuals in their fifties or sixties as representative of ‘late-life’ suicides could lead to misleading interpretations. For example, the lifetime prevalence of major depression, an impor- tant risk factor for suicide at any age, decreases significantly after the age of 65 years15,16. Therefore, its role may be less relevant in older people than in younger people17. It is true that older peo- ple may attribute their depressed mood to physical illness or be ashamed to admit the presence of a mental disorder15. Even early mortality could explain this relatively low prevalence in a popu- lation that is certainly more vulnerable than the younger one18. Conversely, the presence of somatic diseases in suicide increases proportionally with aging, becoming very frequent after the age of 85 years19.

The underestimation of death rates from suicide is an important phenomenon everywhere, far from being trivial20. Suicide death rates of older adults are particularly liable to be underestimated21. In a number of cases, it can be challenging to determine whether the death was caused by a deliberate act (for example, not taking or overdosing on life-saving drugs or an accident or a voluntary fall and so on)21.

In particular, in many Western countries, regulations regarding the prescription of opioids (used to reduce somatic pain) are lax and could give older people fairly easy access to an effective suicide method21. It is then known that the death of an older person usually incurs less investigative interest than the death of a young person or a death associated with a medical procedure22.

Furthermore, cases of ‘silent suicide’ such as those due to vol- untarily stopping eating and drinking (VSED) are generally not registered as suicide cases, even if, in an obvious sense, VSED is a true suicide case, given that the person’s intention is to die23. Food and water are essential for life; deciding to renounce these elements is done to hasten death. Therefore, VSED is a suicide attempt, not

Late-life suicide in an aging world Diego De Leo   1,2 ✉

Suicide is an important problem among older adults and in particular older men. Risk factors for suicide in older adults include the loss of a loved one, loneliness and physical illness. Suicide in older adults is often attributed to the development of depres- sion due to bereavement or loss of physical health and independence. However, suicide prevention in old age requires avoiding overly simplistic therapeutic approaches. This Perspective discusses the impact of social determinants of health, cultural nar- ratives and the coronavirus disease 2019 (COVID-19) pandemic on suicide among older adults and proposes strategies for a multifaceted approach to suicide prevention.

Nature aGiNG | VOL 2 | JAnUARy 2022 | 7–12 | www.nature.com/nataging 7

PersPective NaTuRe agINg

only a desire to reduce food and liquids as a natural consequence of some terminal conditions24. As described by Pope25, VSED has long remained an option to end life in a hidden way; today the debate about VSED is more open, and doctors (especially oncologists) should be well prepared to manage requests of their terminally ill patients. Because VSED represents a possible response to terminal illness, this contributes greatly to its moral acceptability as a form of suicide25.

Other than VSED, patients with terminal illness may ask their doctors to accelerate their death in another way and be assisted to do this. Medical aid for dying is not yet an accepted practice in most countries of the world. Australia has proven to be one of the most active countries in debating these issues, with the Queensland Parliament recently approving the law on voluntary assisted dying (VAD), following a decision similar to that of the parliaments of Victoria, Western Australia, Tasmania and South Australia. To be eligible to access VAD in Queensland, a person must be an adult, have a progressive condition that is expected to cause death within 12 months and causing intolerable suffer- ing, have decision-making capacity and be acting voluntarily and without coercion26.

The spread of euthanasia practices is even more limited. Spain has recently become the sixth country worldwide to acknowledge the right to euthanasia, after the Netherlands, Belgium, Luxembourg, Canada and New Zealand. Several US states allow assisted dying, while Switzerland permits assisted suicide for ‘unselfish reasons’27. Swiss law tolerates assisted suicide when patients effect the act themselves and helpers have no vested interest in their death. The law prohibits doctors, spouses, children or other such related parties from directly participating in one’s death. In Switzerland, two main groups operate in this area: Exit and Dignitas. While Dignitas also assists people from abroad, Exit only supports citizens or perma- nent residents of Switzerland in taking their own life. In 2020, Exit helped 1,282 people, mostly affected by terminal illnesses, to die28. While the number of assisted suicides appears to be growing, to some extent this might reflect the aging population in Switzerland. Total figures of assisted suicide cases are not included in the official count of suicide cases for Switzerland28.

What impact has the pandemic had, if any? Studies that specifically clarify the impact of the COVID-19 pan- demic on rates of death from suicide among older adults are not available yet; however, it is conceivable that the pandemic has a negative impact on suicide in old age29. The 2003 severe acute respi- ratory syndrome (SARS) outbreak in Hong Kong was associated with an increase in the number of suicides in old age, especially in women. Compared to previous years, the increase was 30% of the expected numbers30.

In Japan, after an initial decline in suicide rates during the first wave of the pandemic, a 16% increase was noted during the second wave (July to October 2020), with women experiencing the larg- est increase31. Japan has appointed a minister of loneliness (Tetsushi Sakamoto) after seeing suicide rates in the country rise for the first time in 11 years. Factors such as social distancing, quarantine, per- sonal protective equipment, loneliness and the inability to contact loved ones (even for the last goodbye) have the potential to aggravate anxiety, depression and post-traumatic stress symptoms, potential triggers of self-harm and suicide episodes32,33. The limited availabil- ity of institutions able to provide real-time suicide data (R. Benson et al., unpublished) thus far has provided a non-alarming picture in terms of suicide outcomes. Studies carried out in Australia34 and the UK35 have not shown any particular increase in the number of suicides among older adults. However, in particular for older adults living in nursing homes, the current global health crisis has had traumatizing effects in terms of psychological suffering as well as mortality due to the pandemic36. Apparently, this did not translate into an increase in suicide mortality, despite some subgroups of the

Box 1 | Warning signs of suicide risk in older adults

The individual

• appears sad or depressed most of the time. • feels anxious, agitated or unable to sleep or sleeps all the time. • has frequent and dramatic mood swings. • neglects personal hygiene and no longer pays attention to

physical appearance. • does not want to see friends or family and no longer has a

social life. • expresses disproportionate feelings of guilt or shame. • loses interest in food. • has appreciably increased consumption of cigarettes and

alcohol. • talks about death (for example, ‘I’ve had enough’ or ‘it makes

no sense to continue’). • puts business in order. • labels own things. • makes a will or changes the will. • gives away objects of emotional importance. • has put aside pills and other non-therapeutic drugs. • unexpectedly has visited relatives and friends as if to say

goodbye. (Modified from ref. 82).

Box 2 | Quick glossary of terms

Ageism Discriminating against or stereotyping individuals on the basis of their age.

VSED Act performed by individuals physically and mentally able to eat and drink who consciously refuse to eat and drink with the intent of hastening their own death.

Assisted suicide Suicide effected with the help of another person, usually by providing lethal drugs.

VAD Term used mainly in Australia; it refers to assistance provided to an individual by a health practitioner to end their life.

Euthanasia Action performed by a doctor to end an individual’s life by a painless means, with consent of the patient and/or their family.

Suicide Act to intentionally provoke one’s own death.

Suicidal ideation Broad category of fantasies about, contemplation of, preoccupation with and wishes for suicide.

Suicidal behavior Broad category of suicidal threats, gestures, self-harming behavior and suicide attempts.

SDH Those non-medical factors able to influence health outcomes. They are the conditions in which people are born, grow, work, live and age4.

Human rights of older adults Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter or care or treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives83.

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PersPectiveNaTuRe agINg

population—for example, those who are jail inmates or are socially ‘fragile’ (such as bullied persons)—being more exposed to suicide risk factors37,38.

During the pandemic, many media representations of aging were particularly disturbing and inadequate. They made older adults feel a charge to society and to their families; they made them aware that they might be denied care or considered less deserving of it39,40. These factors can cause feelings of loss of value and meaning and compromise the feeling of independence41,42. Furthermore, people who ask for help might feel exposed, in particular, if the request is due to suicidal behavior, mental illness and substance abuse.

A further element of concern is the difficulty in accessing health care, especially in low- and middle-income countries43. For older people specifically, inadequate access to help is likely to have nega- tive consequences44. This problem tends to worsen in emergency situations, such as in the current pandemic. The reduction of usual care for somatic and psychiatric diseases45, the lack of adequate staff, the limitation of provisions for people living in long-term care facilities46, the abolishment of outpatient visits, home services and public transport as well as long waiting times47,48 are all elements capable of increasing mental distress and thus can cause a rise in suicide risk49.

Actually, as shown in a survey by Carstensen et al.50 on a sample of 945 American individuals between the ages of 18 and 76 years, during the spreading of the pandemic, older adults showed rela- tively greater emotional well-being than younger adults and this persisted even in the face of prolonged stress. Similar results were obtained by another survey performed during March and April 2020 on a sample of 776 individuals aged 18–91 years from Canada and the USA51. Furthermore, another study suggested that older age leads to a greater focus on positive aspects of the initial phases of the pandemic52.

These findings appear to be in line with Carstensen et al.&#

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