Dear Editor, In their letter, Librero et al. have highlighted one of the main issues affecting studies of the financial crisis (and one that we highlighted ourselves in the ‘Strengths and Limitations’ section of the original article), that is, ‘how do we define the financial crisis?’. As recommended when undertaking interrupted time series analyses of imperfectly identifiable events, we do this as objectively as possible by using an independent indicator—in this case gross domestic product (GDP).1 This is the most commonly used indicator to define a financial crisis; we use it in the same way as in similar studies. There is considerable debate among economists as to how to define a recession, but we used the most widely used definition ‘a decline in the seasonally and calendar adjusted real GDP in at least two successive quarters’.2 According to Organisation for Economic Co-operation and Development figures, there were seven successive quarters of decline in GDP in Spain between the second quarter of 2008 and the last quarter of 2009 (Web Appendix 1 of the original article). Librero et al. suggest that we should have used a later date for the onset of the financial crisis given that the government had not yet cut social spending. However, as we have noted elsewhere, the health effects of financial crises are often apparent before changes in economic indicators, reflecting high levels of apprehension at already visible impending difficulties.3 The financial crisis was clearly having an impact on people’s lives even before GDP started to decline given that unemployment was already starting to increase in 2007, and it is stressors such as those arising from job loss that contribute to poor mental well-being.4 It was for this reason that, in our sensitivity analysis, we tested the effect of the crisis starting in July 2007, based on unemployment. In fact, this did yield a similar result to the main model (although not exactly the same as Librero et al. seem to suggest by rounding them both up to 8%). We are not clear what Librero et al. meant by stating that we ‘set a final time of crisis: December 2009 (20% unemployment)’ in the other sensitivity analysis, as this model was based on GDP (and the temporary increase in 2010) and not unemployment. We agree with Librero et al. that further research should model the association between unemployment and suicide, although, as we highlight in the original article, this has already been investigated extensively and there is a well-documented association between the two.5 The aim of our study was, however, to establish whether there was an increase in suicides in Spain in this financial crisis, rather than to investigate the effect of one particular manifestation of the crisis. We also agree that the associations we describe cannot be considered as definitively causal as with any observational study. In fact, in the opening sentence of our ‘Interpretation and Implications’ section, we state that ‘Our study alone cannot establish whether the association found between the financial crisis and suicides is causal’. Nevertheless, we disagree that one should resist publishing alarming results; publication should not be based on the results that are found but rather the importance of the question and the merit of the study. Irrespective of whether these results are alarming, they should be used to aid informed decisions that maximize public health and well-being.
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