852847

review-article2019
SJP0010.1177/1403494819852847V Bartelink et al.Unemployment among young people and mental health

Scandinavian Journal of Public Health, 1–15

Literature Review

Unemployment among young people and mental health: A systematic

review

Vicky H. M. Bartelink1 , Kyaw Zay Ya1, Karin Guldbrandsson2 & Sven

Bremberg2

1Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden, and 2Department of Public

health Sciences, Karolinska Institutet, Public Health Agency of Sweden, Sweden

Abstract
Aim: The aim of this systematic review is to obtain a better understanding of the association between unemployment
among young people and mental health. Methods: After screening the title and abstract of 794 articles drawn from four
electronic databases, 52 articles remained for full-text reading. Of these, 20 studies met the inclusion criteria and were
assessed on methodological quality. All steps were performed independently by two reviewers. Finally, a total of 17 articles
were included in the systematic review. Results: Analysis of cross-sectional studies (N = 5) showed an association between
unemployment among young people and mental health. An effect of unemployment on mental health was found when
considering cohort studies (N = 12) that did not control for confounders (7/7). When controlling for confounders except
mental health at baseline, this effect decreased in most studies leading to mixed results, although the majority (6/8) still
found an effect. However, when taking mental health at baseline into account as one of the confounders, only a minority of
studies (3/8) found a significant effect of unemployment on mental health. Conclusions: This systematic review showed
an association between unemployment among young people and mental health. However, whether there is a
causal relationship is less clear. More evidence from, for example, natural experiments and longitudinal studies
that control for confounding variables, especially mental health at baseline, is required to better understand the
association and potential causation between unemployment among young people and mental health.

Keywords: Unemployment, youth, young people, mental health, systematic review, depression, anxiety

Background benefits, underuse of production potential [4] and

foregone tax payments [5]. On the individual level,
The life-period of ‘emerging adulthood’ is character-
several studies have suggested that unemployed young
ized by high instability in the areas of education, work,
individuals are more likely to have poor physical
love and habitation [1]. This instability in work is also
health [6–7], increased risk of cardiovascular disease
reflected by the percentage of unemployed 15- to
[8], engage more frequently in criminal behaviour [9]
29-year-olds, which was about 15% in the European
and express poorer lifestyle behaviours such as smok-
Union in 2016 [2]. Unemployment in this age group
ing [10], increased alcohol consumption and sub-
is often referred to as ‘unemployment among young
stance abuse [9, 11]. Furthermore, unemployment in
people’ [3] and has been described as having serious
this age group has been associated with higher mor-
consequences for society and for the individual. For
tality rates due to suicide [9, 12], alcohol-related mor-
instance, previous research has shown increased
tality [13], lower income and poorer quality of
financial costs for society due to unemployment

Correspondence: Vicky H. M. Bartelink, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Vinthundsgatan 115,
Apartment 1103, 17441 Sundbyberg, Sweden. E-mail: vickybartelink@hotmail.com

Date received 7 October 2018; reviewed 29 March 2019; accepted 2 May 2019

© Author(s) 2019
Article reuse guidelines: sagepub.com/journals-permissions
DOI: 10.1177/1403494819852847
https://doi.org/10.1177/1403494819852847
journals.sagepub.com/home/sjp
2    V Bartelink et al.
employment later in life [14] and is related to a wide
spectrum of mental health problems such as increased
stress [4] and psychosomatic symptoms [15],
decreased mental wellbeing [16], lower life satisfac-
tion [17], increased risk of depression [18], anxiety
[19], other psychiatric disorders [20] and decreased
mental health later in life [21].
Despite this growing body of literature that
focuses on the relationship between unemployment
among young people and mental health, to the best
of our knowledge no systematic review has been
conducted to summarize and interpret these results.
Previous systematic reviews and meta-analyses have
focused on age-mixed populations, with three
reviews published in 1999, 2005, and 2009 finding
evidence for an association between unemployment
and mental health and supporting a possible causal
relationship [22–24].
Murphy and Athanasou, who included 16 longitu-
dinal studies in their meta-analysis, concluded that
unemployment had negative effects on mental health.
Moving from unemployment to employment was
associated with an improvement in mental health
with a weighted average effect size of Cohen’s d =
0.54 (based on seven studies). Alternatively, the
effect of moving from employment to unemployment
was less clear due to the small number of studies
included (five studies with 616 participants in total)
and showed an average effect size of Cohen’s d =
0.36. The results of this meta-analysis were based on
studies that covered both youth and adulthood and
only two of the 16 studies included in the meta-anal-
ysis controlled for mental health at baseline [24].
In another meta-analysis, McKee-Ryan et al. exam-
ined the effects of unemployment on wellbeing across
104 empirical studies. Although the majority of these
included studies concerned adult unemployment, no
results for specific age groups were reported. Based on
52 cross-sectional studies included in the meta-analy-
sis, it was found that unemployed individuals had
lower mental health compared to employed individu-
als, with a weighted mean effect size of Cohen’s d =
-0.57. In addition, findings from 15 longitudinal stud-
ies showed that reemployment improved mental
health (d = -0.89) whereas eight longitudinal studies
indicated that becoming unemployed decreased men-
tal health (d = -0.38). Based on the performed analy-
ses, it was concluded that there is strong support for a
causal relationship between unemployment and men-
tal health [23]. Unfortunately, no information was
given on how confounders, including mental health at
baseline, were controlled for.
Thirdly, Paul and Moser compared the mental
health of unemployed and employed persons using the
results of 237 cross-sectional and 87 longitudinal
studies. Results from the cross-sectional studies
showed that unemployed individuals had higher levels
of distress and lower wellbeing than employed indi-
viduals, with an overall average effect size of Cohen’s d
= 0.54. Longitudinal studies indicated a significant
increase in distress for individuals that became unem-
ployed (d = 0.19), whereas a decrease in distress was
observed after reemployment (d = -0.35). Notably, for
youths that became unemployed right after school, no
significant increase in distress was observed. From
this, it was concluded that unemployment has a nega-
tive effect on overall mental health with Cohen’s d =
0.5122 [22]. Unfortunately, no separate analysis was
provided for studies that controlled for confounding
variables including mental health at baseline and
results were not reported for the different age groups.
Within the literature available on the relationship
between unemployment and mental health, one of
the key concerns is the distinction between selection
and exposure effects of unemployment. An exposure
effect would mean mental health is the result of
unemployment and would thus propose a causal
relationship, whereas a selection effect would assume
unemployment is the result of mental ill health and
the association between unemployment and mental
health occurs because individuals with lower mental
health have more difficulties in finding a job and have
a higher chance to become unemployed [22]. The
problem of causality is impossible to solve using evi-
dence from cross-sectional studies, because these
data do not contain any information regarding the
direction of the association [26]. From a research
point of view, an experimental design where individ-
uals are randomized into either the unemployment or
the employment condition would provide the best
evidence for a possible causal relationship between
unemployment and mental health. Obviously this is
not possible due to ethical reasons; however, cohort
studies that examine the relationship between unem-
ployment and mental health are widely available.
Although ultimately experimental designs will be
necessary to find evidence for a causal relationship
between unemployment and mental health, these
longitudinal cohort studies that control for con-
founders including mental health at baseline could
provide support for a causal hypothesis [27].
Aim
The aim of this systematic review is to better under-
stand the association between unemployment among
young people and mental health.The following research
question will be answered: what effect does unemploy-
ment between the ages of 16 and 30 have on the mental
health of individuals in high-income countries?
 Unemployment among young people and mental health   3
Methods
Terms and definitions
To operationalize mental health the World Health
Organization (WHO) definition was used, which
explains mental health as ‘a state of wellbeing in
which the individual realizes his or her own abilities,
can cope with normal stresses of life, can work pro-
ductively and fruitfully, and is able to make a contri-
bution to his or her community’ and is ‘not just the
absence of mental disorders’ [28]. In addition, anxi-
ety and depression [29] were used as these are the
two most common mental health disorders among
youth. Furthermore, to have a broad scope for stud-
ies, mental ill health was broadly operationalized by
decreased mental wellbeing, feelings of stress or dis-
tress, feelings of depression or anxiety, or diagnosed
depression or anxiety disorders.
‘Unemployment among young people’ was opera-
tionalized as a self-reported or registered period of
not working in paid employment between the ages of
16 and 30 years.
Because the economic situation of a country can
influence the magnitude of consequences of unem-
ployment, for example due to differences in unem-
ployment protection systems and equality of income
distribution [22], only high-income countries were
compared in this systematic review. The World Bank
classification system [30] was used to define high-
income countries.
Search strategy
Three electronic databases (PubMed, Web of Science
and PsycInfo) were used to systematically search for
articles that assess the association between unem-
ployment among young people and mental health
(see Table I for the search strategies of PubMed, Web
of Science, PsycInfo). Google Scholar was searched
as a supplementary source using the search terms
‘youth unemployment’ and ‘mental health’. The first
four pages of hits were compared with the articles
found through the other electronic databases. Only
unique articles were included. The search was lim-
ited to English language articles published in a peer-
reviewed journal between 1 January 2000 and 29
January 2018. Additional articles were searched
through reference lists of included articles.
Inclusion and exclusion criteria
Articles were included if they described the associa-
tion of unemployment between the ages of 16 and 30
years and were performed in high-income countries.
To assess whether the study was performed in a high-
income country, the World Bank classification [30]
was used. Articles were excluded when (a) they were
not available in full text; (b) p values were not provided
in the results; (c) the exposure measure was not
defined as a period of unemployment between 16 and
30 years old; (d) the outcome measure did not consist
of mental health problems (operationalized as low
mental wellbeing, stress or distress, feelings of depres-
sion or anxiety, or diagnosed depression or anxiety dis-
orders); or (e) mental health and unemployment were
not assessed within the same individual.
Study selection and evaluation
Two reviewers (VB and KZY) first individually
screened titles and abstracts for suitable articles and
then discussed the results and solved disagreements
by consensus. Articles eligible for full-text assessment
were handled in the same manner and were first inde-
pendently assessed based on the inclusion and exclu-
sion criteria by the same reviewers, then discussed to
reach consensus on which articles to include. After
this, the methodological quality of the included arti-
cles was independently assessed by the same reviewers
using the Effective Public Health Practice Project
(EPHPP) quality assessment tool [31]. The EPHPP
tool has shown to have construct and content validity
[32] and is proven to be reliable [33]. After reaching
consensus on the quality of the articles between the
reviewers, studies with a weak global rating were
excluded. The results of the quality assessment can be
found in Table II. Data of included studies were
extracted by the first author (VB) using a data extrac-
tion sheet in Excel. Information of the following data
characteristics was extracted: authors, title, year, aim,
study design, name of cohort (if applicable), follow-up
time (if applicable), sample size, response rate, age
range, sex distribution, study setting, definition of
exposure measure, assessment of mental health at
baseline, description of outcome measure, type of sci-
entific analysis, measure of effect (mean with standard
deviations or odds ratios with confidence intervals),
p values, limitations and strengths and conclusions.
Due to the heterogeneity of included studies, it was
not possible to do a quantitative synthesis of the
results, instead a narrative synthesis was done. The
review was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [34].
Results
Selection of studies
A flow chart describing the article selection process
according to the PRISMA guidelines [34] can be found
in Figure 1. The initial electronic search provided a total
4    V Bartelink et al.
Table I. Search strategies for PubMed, Web of Science and PyscInfo (29 January 2018).

Search Keywords Limitations Number of hits

PubMed
#1 Unemployment[MeSH] 6159
#2 Mental health[MeSH] OR mental disorders[MeSH] OR 1,213,839
depression[MeSH] OR anxiety[MeSH]
#3 Adolescent[MeSH] OR young adult[MeSH] 2,125,602
#4 #1 AND #2 AND #3 642
#5 #4 Publication date 2000– 436
#6 #5 English language 413
Web of Science
#1 Unemployment 35,580
#2 Anxiety OR depress* OR stress OR “mental ill-health” OR “mental 1,760,615
health” OR “mental disorder*”
#3 Adolescen* OR “young adult” OR youth 463,664
#4 #1 AND #2 AND #3 457
#5 #4 Publication date 2000– 383
#6 #5 English language 361
PsycInfo
#1 Unemployment[SubjectHeadings] 3897
#2 Mental Health[SubjectHeadings] OR Well Being[SubjectHeadings] 868,130
OR Mental Disorders[SubjectHeadings] OR Behavior
Disorders[SubjectHeadings] OR Anxiety[SubjectHeadings] OR
Stress[SubjectHeadings]
#3 Adolescen* OR young OR youth OR “emerging adulthood” 431,193
#4 #1 AND #2 AND #3 201
#5 #4 Publication date 2000– 108
#6 #5 English language 101

Table II. Quality assessment of the studies (N = 20) using the this point. A total of 52 articles were assessed for eligi-
Effective Public Health Practice Project (EPHPP) quality assess- bility in full text, where after a total of 20 articles
ment tool.31
remained for quality assessment. During quality assess-
Author (year) Global rating ment, three more articles were excluded. Finally, a total
of 17 studies met all criteria and were included in this
Aquilar-Palacio et al. (2015) Moderate
Axelsson and Ejlertsson (2002) Moderate systematic review. An overview of the distribution of
Bacikova-Sleckova et al. (2007) Weak different study characteristics among the included stud-
Baggio et al. (2015) Strong ies can be found in Table III.
Bjarnason and Sigurdardottir (2003) Moderate
Breslin and Mustard (2003) Strong
Crowe and Butterworth (2016) Strong
Fergusson et al. (2001) Strong Cross-sectional studies
Fergusson et al. (2014) Strong
Goldman-Mellor et al. (2016) Strong Four out of five cross-sectional studies reported
Hammarström and Janlert (2002) Strong mainly significant differences or increased risk of
Huegaerts et al. (2017) Weak mental health problems for unemployed young peo-
McGee and Thompson (2015) Moderate ple compared to employed young people. Both
Mossakowski (2011) Strong
Reine et al. (2004) Strong Axelsson and Ejlertsson and Bjarnason and
Strandh et al. (2015) Strong Sigurdardottir found a significantly higher level of
Strandh et al. (2014) Strong mental health problems among youth up to 24 years
Taris (2002) Weak old that were registered as unemployed for at least 3
Thern et al. (2017) Strong
Virtanen et al. (2016) Strong months compared to employed individuals [4, 15].
In addition, Bjarnason and Sigurdardottir found in
Global rating is the overall judgment based on the assessment of their sample of youths from different European
six domains: strong = no weak ratings, moderate = one weak rat- countries that this difference remained significant
ing, weak = two or more weak ratings.
when comparing unemployment with other labour
market outcomes (permanent job, temporary job,
of 878 articles, of which 794 remained after removal of returning to school or leaving the labour market)
duplicates. Subsequent screening of titles and abstracts and that moving beyond unemployment was associ-
further reduced this number to 51 articles that remained ated with a reduction in mental health problems [4].
for full-text assessment. Based on the reference lists in McGee and Thompson showed that 18- to 25-year-
the selected articles, one more study was included at old unemployed Americans had up to three times
 Unemployment among young people and mental health   5
Figure 1.  Flow chart of study selection according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines.
higher odds of depression compared to employed
individuals [35] and Goldman-Mellor et  al. found
that 18-year-olds Not in Education Employment or
Training (NEET) in Great Britain had a higher risk
for both major depressive and generalized anxiety
disorder than non-NEETs [36]. Only one study
found mixed results: Aguilar-Palacio et  al. found a
significant higher risk for mental health problems for
young Spanish men (aged 16 to 24) that were unem-
ployed compared to employed young men in 2012 (a
recession period). However, they failed to find simi-
lar results in 2006 (no recession period). For women,
no significant differences were found between
employed and unemployed individuals either in
2006 or 2012 [37].
Cohort studies – not controlling for confounders
Of the 12 cohort studies, seven provided information
on the effect of unemployment at a young age on
mental health without controlling for confounders.
All of these studies (seven out of seven) found
mainly significant effects of youth unemployment on
mental health.
Cohort studies – controlling for confounders
except mental health at baseline
When controlling for confounding variables (see Table
III for the confounders included in the different stud-
ies) but without considering mental health at baseline,
the effect of unemployment at a young age on mental
health was reduced in most cases compared to not
controlling for confounders. Nevertheless, the major-
ity of the studies (six out of eight studies) still found
mainly significant effects of unemployment among
young people on mental health.
For instance, unemployment at age 20 to 24 in
Australia was significantly associated with depression at
age 24 to 32 [18]. A similar effect was observed in the
United States, where unexpected unemployment
between age 19 and 27 was found to have a significant
Table III. Characteristics of included studies.

Author (year) Setting Study Sample Exposure Outcome measures Follow Controlled for confounding Key findings
design up variables

Aquilar-Palacio Spain Cross- N = 3701 Self-reported Mental health during the past No Family social class, • Unemployed men (< 1 year)
et al. (2015)37 sectional Age: 16-24 years. unemployment few weeks measured with the educational level, age showed a higher risk of mental
58% men, 42% General Health Questionnaire health problems than workers in
women (GHQ-12) 2012
6    V Bartelink et al.

• No significant differences was

found for unemployed men in
2006 or women in 2006 and
2011/12 compared to workers
• When both time points were
considered: unemployed men
(⩾ 1 year) showed a higher
risk of mental health problems
than workers, but no significant
differences were found for women,
unemployed men (< 1 year), or
men that never worked compared
to workers.
Axelsson and Sweden Cross- N = 515 Registered Mental health based on No Civil status, living situation, Unemployed men and women showed
Ejlertsson sectional Age: 20–25 years. unemployment items: tearfulness, dysphoria, education level more mental health problems than
(2002)15 46% men, 54% ⩾ 3 months sleeping disturbance, employed men/women.
women restlessness, general fatigue,
irritability
Bjarnason and Denmark, Finland, Cross- N = 7307 Registered Psychological distress assessed No Duration of unemployment, • Unemployed men and women
Sigurdardottir Iceland, Norway, sectional Age 18–24 years. unemployment using Hopkins Symptoms perceived public/personal (⩾ 3 months) that were still
(2003)4 Scotland, Sweden 54% men, 46% ⩾ 3 months 6 Checklist for anxiety and negative attitudes towards unemployed at the time of the
women months prior to depression employment, support from study (after 6 months) showed
the study parents, economic situation, significant higher levels of
education level, age, living psychological distress than their
situation counterparts in other labour
market outcomes.
• Less distress was associated with
moving beyond unemployment to:
a permanent job, a temporary job,
returning to school, or leaving the
labour market.
McGee and US Cross- N = 1525 Self-reported Depressive symptoms in No Disability status, smoking, Unemployed individuals (<1 year
Thompson, sectional Age: 18–25 unemployment previous 2 weeks assessed BMI, health insurance status, and ⩾ 1 year) showed a higher risk of
(2015)35 59% men, 41% by the Patient Health sex, race, marital status, depression than employed individuals.
women Questionnaire (PHQ-8) education
Goldman-Mellor Great Britain Cross- N = 2066. Self-reported • Depression and No Sex, family socioeconomic NEET status was significantly
et al. (2016)36 sectional/ Age (M): 18 years. NEET status generalized anxiety status, neighbourhood associated with major depressive
Cohort 47% men, 53% (not studying, disorder over the previous socioeconomic context, episode and generalized anxiety
women working in paid 12 months assessed by childhood IQ, childhood disorder compared to non-NEET
employment or Diagnostic Interview reading skills, childhood individuals.
in apprenticeship Schedule mental health problems
training)
Table III.  (Continued)

Author (year) Setting Study Sample Exposure Outcome measures Follow Controlled for confounding Key findings
design up variables

Baggio et al. Switzerland Cohort N = 5990 Follow-up Self-reported • Mental health status in 15 Language, age, family No significant effect was found for
(2015)41 rate 87.2%. Age (M): NEET status the previous four weeks months income, parents’ education NEET status at baseline as predictor
20 at baseline and 21.3 (not studying, assessed using the Short level of mental health or depression at
at follow-up. working in paid Form Health Survey. follow up.
100% men employment, • Level of depression in
or training) the previous two weeks
including assessed by the WHO’s
participants Major Depressive
currently looking Inventory
for work and not
looking for work.
Breslin and Canada Cohort N = 1868 Follow-up Registered • Distress over the past 2 years Gender, age, marital status, No significant effect was found for 18–
Mustard rate 88.9%. Age 18–30 unemployment month based on items: living situation, unusual 30 year olds of becoming unemployed
(2003)42 years. everything feels an effort, life events, chronic medical and remaining unemployed after
54% men, 46% so sad nothing cheers conditions, outcome variable 2 years of distress or depression at
women you up, nervous, restless at time 1 follow up.
and fidgety, hopeless,
worthless.
• Presence of depression
in the last 12 months
assessed by the Composite
International Diagnostic
Interview
Crowe and Australia Cohort N = 2404 Response Self-reported Symptoms of depression in 8 years Age, gender, marital status, Unemployment and working part time
Butterworth, rate at follow-up 1: unemployment the prior 4 weeks assessed physical health, dependent but looking for full-time employment
(2016)18 83% and 2: 89%. by the Goldberg Depression children, education level was significantly associated with
Age: 20–24 years at Scale depression at follow up.
baseline. 48% men,
52% women
Fergusson et al. New Zealand Cohort N = 1053. Self-reported Depression in the past 2 years 2 years Measures of family social No significant association was found
(2001)51 Age (M) 18 at unemployment assessed by the Composite background, measures of for the effect of unemployment on
baseline. during 16–18 International Diagnostic family functioning, measures depression at follow up.
Women 52%, men years old and Interview of parental adjustment,
48% 18–21 years old individual characteristics,
cognitive ability and school
achievement, measures
of behaviour and peer
affiliations, history of
psychiatric disorder and
suicidal behaviour prior to
age 16
Fergusson et al. New Zealand Cohort N = 1056. Follow-up Self-reported Depression and anxiety 12 years Reversed causality and non- • A significant effect was found for
(2014)44 rate 80% unemployment disorders in the past 12 observed confounding duration of unemployment on
Age (M) : 18 years at during 16–18, months assessed by the variables major depression
baseline, follow up at 18–21, 21–25, Composite International • No significant effect was
21, 25 and 30. Women and 25–30 years Diagnostic Interview found between duration of
52%, men 48% old unemployment on anxiety
disorder.

(Continued)
Unemployment among young people and mental health   7
Table III.  (Continued)

Author (year) Setting Study Sample Exposure Outcome measures Follow Controlled for confounding Key findings
design up variables
8    V Bartelink et al.

Hammarström Sweden Cohort N = 1083 Follow-up Self-reported Psychological symptoms 14 years Health situation at 16, • Unemployment (> 0.5 years)
and Janlert rate 96% Age (M): unemployment during the previous year working class background between 16 and 21 years was
(2002)27 16 years at baseline, assessed by a composite index significantly associated with
follow-up at 18, 21 of nervous symptoms and increased risk for psychological
and 30. depressive symptoms symptoms at age 30 for men and
52% men and 48% women.
women • No significant effect was found
for unemployment (>1.5 years)
between 22 and 30 years on
psychological symptoms at age 30.
Mossakowski US Cohort N = 6932 Follow- Self-reported Depressive symptoms assessed 15 years Gender, age, race, marital Unexpected unemployment at age
(2011)38 up rate 89.2%. Age: unemployment by the Epidemiological status, currently a parent, 19–27 predicted higher levels of
14-22 at baseline, Studies Depression scale currently employed/ depression at age 27–35 and 29–37
27-35 at first follow-up (CES-D) out of the labour force, compared to expecting to become
and 29-37 at second parental education, parental employed and becoming employed
follow up occupational prestige, prior at age 19–27. When controlling for
depressive symptoms, prior confounding variables, the effect
self-esteem of unexpected unemployment on
depression became non- significant.
Reine et al. Sweden Cohort N = 1083 Follow-up Self-reported Psychological symptoms 14 years Daily smoking, having • Unemployment (⩾6 months)
(2004)39 rate 96%. Age (M): 16 unemployment during the previous year children, financial situation, between age 16–21 was associated
years at baseline and assessed by a composite index working class, control, with poor psychological health at
follow-up at age 18, 21 of nervous symptoms and unemployed relatives, work age 21 for men and women.
and 30. depressive symptoms commitment • Unemployment (⩾6 months)
52% men and 48% between age 25–30 is associated
women with poor psychological health
at age 30 in men. No significant
effect was found for 30-year-old
women.
Strandh et al. Sweden Cohort N = 1083 Follow-up Self-reported Psychological symptoms 27 years Gender, health situation at Exposure to open youth
(2015)43 rate 94%. open during the previous year age 16, parental employment unemployment age 18–21 was
Age: 18–21 at baseline unemployment assessed by a composite index situation, social class and significantly associated with
and follow-up at age (actively seeking of nervous symptoms and health problems at age 16, internalized mental health symptoms
21 and 42. Women: for work while depressive symptoms and living with both parents at age 21 and at age 43.
48%, men: 52% not being in at age 16
employment,
education or
training)
Table III.  (Continued)

Author (year) Setting Study Sample Exposure Outcome measures Follow Controlled for confounding Key findings
design up variables

Strandh et al. Sweden Cohort N = 1083 Follow-up Self-reported Psychological problems 27 years Gender, parental social • Cumulative unemployment of ⩾ 6
(2014)52 rate 94%. Age (M): 16 unemployment during the previous year class at age 16, parental months between age 18–21 had a
years at baseline and assessed by the Psychological involuntary unemployment significant effect on psychological
follow-up at age 18, Problems Index (PPI) at age 16 problems at age 21, 30 and 42.
21, 30 and 42. • Consecutive unemployment of ⩾ 6
Women: 48%, men: months between age 21–30 had a
52% significant effect on psychological
problems at age 30, but no
significant effect at age 42.
• Exposure to unemployment
between age 18–21 and 21–30 had
a significant effect on psychological
problems at age 30, but not at
age 42.
Thern et al. Sweden Cohort N = 6410 (crisis Registered Affective (mood) disorders 17 years Sex, age and country of • Effect of unemployment at age
(2017)40 cohort) with follow-up unemployment and nervous-stress related birth, prior own mental 17–24 on nervous and stress-
rate 89%. disorders diagnosed using the diagnosis before exposure related disorders after 17 years was
N = 8162 (non-crisis International Classification and assessment by the significant in non-crisis cohort but
cohort) with follow-up of Disease on the national Labour Force Survey, not in the crisis-cohort.
rate 90%. hospital discharge register parental socioeconomic • No significant effects were found
Age 17–24 at baseline data index, parental education and for affective (depression, bipolar,
and 34–35 at follow up parents’ mental health. anxiety) disorders.
Virtanen et al. Sweden Cohort N = 1001 (Cohort 65) Self-reported Depression and anxiety were 22 years Gender, parental • For Cohort 65, unemployment
(2016)19 with follow-up rate unemployment assessed by a composite (Cohort socioeconomic status, mental (25–183 weeks) at age 21–25 had
94%. 52% men, 48% measure of internalized 65) and health at baseline, recent a significant effect on depression
women symptoms 18 years unemployment at follow up and anxiousness at age 43.
N = 686 (Cohort 73) (Cohort There was no significant effect
with follow-up rate 73) of unemployment (2–24 weeks)
86%. 50% men, 50% on depression and anxiousness at
women. age 43.
Age 21–25 at baseline • For the Cohort 73, unemployment
and followed-up at age (1–15 weeks /16–126 weeks) had
39/43 a significant effect on anxiousness
and at age 39. No significant effect
was found for unemployment on
depression.

BMI: body mass index; NEET: Not in Employment, Education or Training; WHO: World Health Organization.
Unemployment among young people and mental health   9
10    V Bartelink et al.
effect on depression at age 29 and 37 [38]. Additionally,
high exposure (16 to 183 weeks) of self-reported unem-
ployment at age 21 to 25 in Sweden was found to have
a significant effect on depression and anxiousness at age
39 or 43 in times of economic boom and recession [19].
Age-related differences were observed in a study by
Strandh et al., which showed that although unemploy-
ment of more than 6 months among Swedish youths
between age 18 and 21 had a significant effect on psy-
chological problems at age 21, 30 and 42, unemploy-
ment of more than 6 months at age 21 to 30, or being
unemployed both at age 18 to 21 and at age 21 to 30,
had a significant effect on psychological problems at
age 30 but not at age 42 [21]. Similarly, age- and sex-
related differences were observed by Reine et al., who
showed that being unemployed for more than 6 months
between age 16 to 21 was significantly associated with
poor psychological health at age 21 for both Swedish
men and women, whereas more than 6 months of
unemployment between the age of 25 and 30 was sig-
nificantly associated with poor psychological health for
men at age 30, but not for women [39]. Finally, Thern
et al. found that registered unemployment at age 17 to
24 for more than 6 months significant effected mental
health at age 34/35. In addition, total unemployment
(including short-term unemployment) affected nerv-
ous- and stress-related disorders at times of financial
prosperity, but not at times of financial crisis in Sweden,
but did not affect depression and anxiety disorders.
However, because inpatient discharge data were used to
assess these outcomes, only patients that needed inpa-
tient care were captured in their analysis [40].
In contrast, in a cohort of Swiss men, no signifi-
cant effect was found for NEET status at a mean age
of 20 on mental health or depression 15 months later
[41]. Furthermore, Breslin and Mustard found no
significant effect of registered unemployment in
Canada at age 18 to 30 on clinical depression or dis-
tress after 2 years of follow up [42].
Cohort studies – controlling for confounders
including mental health at baseline
Eight studies reported results on the effect of unem-
ployment among young people on mental health
while controlling for confounders including mental
health at baseline. The inclusion of this confounder
reduced the effect size in all of these eight studies and
resulted in mixed results: three out of eight studies
showed mainly significant effects of unemployment
at young age on mental health, one study found
mixed effects, whereas four studies did not find sig-
nificant effects.
Three studies showed significant effects when
controlling for confounders including mental health
at baseline: Strandh et al. showed that Swedish 18- to
21-year-old NEETs who were actively seeking for
work had more internalized mental health problems
at age 21 and 43 than employed individuals [43].
Thern et  al. still found a significant effect of regis-
tered unemployment for more than 6 months at age
17 to 24 on mental health at age 34/35 when control-
ling for mental health at baseline [40]. In addition,
Virtanen et al. still found a significant effect of high
exposure (16 to 183 weeks) of self-reported unem-
ployment at age 21 to 25 on depression and anxious-
ness at age 39 to 43 in times of economic boom, but
no longer on depression in a period of recession [19].
One study found mixed effects: Hammarström
and Janlert found that more than 6 months of unem-
ployment between age 16 and 21 was significantly
associated with increased risk of psychological symp-
toms at age 30 for both men and women. However,
no significant effect was found for more than 18
months of unemployment between age 22 and 30 on
psychological symptoms at age 30 in Sweden [27].
Four studies found no significant effect: Breslin
and Mustard still did not find a significant effect for
registered unemployment on depression or distress
after two years of follow up when controlling for
mental health at baseline [42]. Fergusson et al. found
no effect in a New Zealand cohort study of unem-
ployment between ages 16 to 21 on major depressive
disorder at age 21 after controlling for confounding
variables including mental health at baseline [9].
Similarly, in another study by Fergusson et al. using
the same cohort, the significant effect of duration of
unemployment between age 16 to 25 on major
depression and anxiety disorder as a pooled result for
the ages 18, 21, 25 and 30 disappeared when control-
ling for confounders including mental health at base-
line [44]. Lastly, Mossakowski et al. no longer found
a significant effect of unexpected unemployment
between age 19 and 27 on depression at age 29 and
37 when controlling for mental health at baseline in
addition to other confounding variables [38]. A sum-
mary of the findings of the cohort studies can be
found in Table IV.
Discussion
Discussion of findings
The aim of this study was to better understand the
association between unemployment among young
people and mental health. The results of this study
show that unemployment at a young age is associ-
ated with mental health problems. Reviewing the
results of cross-sectional studies, the findings were
largely consistent in finding an association between
Table IV. Summary of effects of unemployment among young people on mental health expressed in Beta coefficient (β) or OR found in cohort studies (N =12).
Author (year)
Baggio et al. (2015)41
 
Crowe and Butterworth (2016)18
Strandh et al. (2014)21
 
 
Reine et al. (2004)39
 
 
 
Breslin & Mustard (2003)42
 
Fergusson et al. (2001)9
Ferguson et al. (2014)53
 
Hammarström and Janlert (2002)27
 
 
 
Mossakowski et al. (2011)38
Strandh et al. (2015)43
 
Thern et al. (2017)40
 
Virtanen et al. (2016)19
 
 
 
*= p <0.05; ** = p <0.01; *** = p <0.001.
NS: not significant; NA: information not available; MH: mental health; OR: odds ratio.
Not controlled for confounding factors Controlled for confounding factors Controlled for confounding factors including
mental health at baseline
N/A Depression β 0.093 (NS) N/A
N/A Mental health β -0.028 (NS) N/A
Depression: OR 2.40 (1.74–3.32)* Depression: OR 1.55 (1.06–2.25)* N/A
MH (exposure age 18–21): β 0.25 (0.09–0.41)*** MH (exposure age 18–21): β 0.21 (0.05-0.37)*** N/A
MH (exposure age 21–30): β 0.32 (0.07–0.58)* MH (exposure age 21–30): β 0.34 (0.09–0.59)** N/A
MH (exposure age 18–21 and 21–30): β 0.99 MH (exposure age 18–21 and 21–30): β 0.97 N/A
(0.74–1.23)*** (0.72–1.21)***
MH at age 21 (men): OR 4.97 (2.79-8.86)* MH at age 21 (men): OR 4.79 (2.24-10.23)* N/A
MH at age 30 (men): OR 2.64 (1.33–5.24)* MH at age 30 (men): OR 2.29 (1.08–4.85)* N/A
MH at age 21 (women): OR 4.03 (2.25–7.19)* MH at age 21 (women): OR 2.71 (1.24–5.88)* N/A
MH at age 30 (women): OR 1.48 (0.62–3.53) (NS) MH at age 30 (women): OR 1.38 (0.55–3.44) (NS) N/A
N/A Depression: OR 0.89 (0.3-2.8) (NS) Depression: OR 0.83 (0.3–2.6) (NS)
N/A Distress β -0.002 (NS) Distress β -0.052 (NS)
β 0.141** N/A β 0.103 (NS)
Depression: OR 1.23 (1.12–1.35) *** N/A Depression: OR 1.17 (1.00–1.37) (NS)
Anxiety: OR 1.15 (1.03–1.28)** N/A Anxiety: OR 1.10 (0.93–1.29) (NS)
N/A N/A MH (exposure age 16–21, men):
OR 2.6 (1.4-4.7)*
N/A N/A MH (exposure age 16–21, women):
OR 1.9 (1.0–3.5)*
N/A N/A MH (exposure age 22–30, men):
OR 1.5 (0.9–2.6) (NS)
N/A N/A MH (exposure age 22–30, women):
OR 1.5 (0.8–2.6) (NS)
N/A β 0.70** β 0.39 (NS)
N/A N/A MH at age 21: OR 2.48 (1.57–3.60)***
N/A N/A MH at age 43:
OR 1.71 (1.20–2.43)**
MH (exposure during economic recession): OR 3.08 MH (exposure during economic recession): OR 3.27 MH (exposure during economic recession): OR
(1.97–4.82)* (2.08–5.15)* 2.70 (1.71–4.28)*
MH (exposure during economic boom): OR 4.17 MH (exposure during economic boom): OR 4.05 MH (exposure during economic boom): OR
(2.52–6.90)* (2.44–6.72)* 3.33 (2.00–5.57)*
Anxiousness (exposure during economic boom): OR Anxiousness (exposure during economic boom): OR Anxiousness (exposure during economic boom):
2.65 (1.81–3.88)* 2.65 (1.80–3.92)* OR 2.19 (1.46–3.30)*
Depression (exposure during economic boom): OR Depression (exposure during economic boom): OR Depression (exposure during economic boom):
2.43 (1.68–3.50)* 2.37 (1.63–3.45)* OR 1.85 (1.25–2.74)*
Anxiousness (exposure during economic recession): Anxiousness (exposure during economic recession): Anxiousness (exposure during economic
2.25 (1.45–3.47)* 2.33 (1.50–3.63)* recession): 2.13 (1.33–3.39)*
Depression (exposure during economic recession): Depression (exposure during economic recession): Depression (exposure during economic
OR 1.46 (0.96–2.21) (NS) OR 1.55 (1.01–2.37) recession): OR 1.38 (0.89–2.14) (NS)
Unemployment among young people and mental health   11
12    V Bartelink et al.
unemployment among young people and mental
health: almost all studies found evidence for a sig-
nificant difference in the mental health of unem-
ployed compared to employed young people.
However, to answer the research question ‘what
effect does unemployment between the age of 16
and 30 have on the mental health of individuals in
high-income countries?’, the results of the cohort
studies should be considered. Results of cohort
studies not controlling for confounding variables
consistently showed an effect of unemployment on
mental health: seven out of seven studies found a
significant effect. However, controlling for con-
founding variables but not considering mental
health at baseline already resulted in a reduced
effect in most cases as well as mixed results: six out
of eight studies showed a significant effect.
Importantly, when controlling for confounding fac-
tors including mental health at baseline, the
observed effects decreased in all cases and only a
minority of the studies (three out of eight) showed
a significant effect.
Interpretation of results
To our knowledge, this systematic review was the first
to assess the association between unemployment and
mental health specifically for young people. The find-
ing of an association between unemployment and
mental health is in line with previous meta-analyses
and systematic reviews on unemployment and mental
health among mixed-age groups [22–24]. However,
our findings do not replicate the results of these stud-
ies that support a causal relationship between unem-
ployment and mental health. There are several reasons
that might explain the difference between the conclu-
sions of the current study and previous systematic
reviews and meta-analyses.
First of all, our study shows that outcomes differ
quite substantially depending on whether confound-
ers are considered. As previous reviews did not dif-
ferentiate studies based on the inclusion of
confounders, it remained unclear how much of the
relationship between unemployment and mental
health found in previous meta-analyses could be
explained by confounding factors, such as mental
health at baseline, low socioeconomic status of the
parents, etc. The importance of a number of factors
that could potentially confound this relationship have
been described in previous studies. For example,
mental health problems at an early age were found to
have a significant effect on mental health further into
adulthood [27, 38] and worrying about family
finances was shown to lead to more mental health
problems among adolescents [45].
Second, the present review only considered evi-
dence from cohort studies specifically related to
unemployment to answer the research question. In
contrast, previous systematic reviews and meta-anal-
yses on mixed age groups combined evidence from
studies investigating the effect of both unemploy-
ment and reemployment and in most cases included
evidence from cross-sectional studies to reach their
conclusion. However, even in these reviews, a small
effect of unemployment on mental health was
observed when only considering cohort studies [22–
25]. In addition, Paul and Moser provide separate
evidence from a natural experiment on a factory-clo-
sure study and showed the effect of unemployment
on mental health decreased tremendously compared
to cohort and cross-sectional studies [22].
Third, the present study focused specifically on
unemployment among young people instead of a
mixed-aged population as has been done in previ-
ous reviews and meta-analyses [22–24]. The effect
of unemployment on health may differ between
young people and adults based on differences in
financial and family responsibilities as well as dif-
ferences in the role that work plays in identity
development [35, 39, 46]. This is also supported by
the findings of Paul and Moser, who demonstrate
that that a significant effect for adults can only be
found when analysing evidence for adults and
youths separately [22].
Methodological considerations
The main strength of this study is the overall good qual-
ity of the included studies. In total, 13 of the 17 included
studies had a global rating of ‘strong’ in the quality
assessment. Another strength is that only the evidence
from cohort studies was used to assess the effect of
unemployment on mental health and a differentiation
was made between results without controlling for con-
founding variables and controlling for confounding
variables, with and without mental health at baseline.
A limitation of the study is the heterogeneous
character of the included studies due to differences
in time of measurement, unemployment character-
istics and definition of mental health. This limita-
tion of heterogeneity was reduced by including only
studies that measured mental health problems as
stress, low mental wellbeing, depression, or anxiety
and only focusing on high-income countries to
increase the comparability of the studies. A second
limitation is the over-representation of Swedish
studies. Five of the 12 cohort studies are based on
data from the Northern Swedish Cohort, which
causes an over-representation of this cohort.
However, this cohort was characterized by a high
 Unemployment among young people and mental health   13
response rate, a long follow-up time and all studies
received a global rating of ‘strong’ in the quality
assessment. Therefore, these studies were expected
to hold reliable and valuable data, which should not
be disregarded. Moreover, as the included studies
had different baseline measures, follow-up times
and/or outcome measures, no quantitative synthesis
of results was done. Instead, studies were described
separately in a narrative synthesis.
Implications
The results of this study show that unemployed
young people are a high-risk group for mental health
problems. Ensuring appropriate services and sup-
port for this group should therefore be a priority for
policymakers not only from an economic perspec-
tive but also from a public health perspective.
However, to produce a sufficient knowledge base to
inform policymakers on this topic, more research
should be done to increase the understanding of the
effect of unemployment among young people on
mental health and the role that confounders play in
this relationship.
Future research
To increase comparability across studies, unemploy-
ment should be defined more uniformly in future
studies. This would make it possible to cluster results
in a meta-analysis. In addition, a greater focus on the
role of confounders, including mental health at base-
line, would increase the understanding of how much
of the association between unemployment at a young
age and mental health is causal and what role con-
founders play in this relationship. This evidence
would strengthen the hypothesis that there is an
exposure effect of unemployment on mental health.
A second area of future research should consider
the quality of employment when examining the effect
of unemployment among young people on mental
health. Changes in the labour market in Western
European countries have led to more flexible work-
ing arrangements that also influence the quality of
work [47]. This is in line with a suggestion made by
Dooley, who points out that to gain a full picture of
the effect of unemployment on mental health,
employment should be considered as a continuous
variable instead of a dichotomized one by also taking
into account the quality of employment [48]. One of
the few studies focusing on quality of employment in
the relationship between unemployment and mental
health showed that underemployment is associated
with internalized mental health problems [49]. In
addition, low job security is shown to be associated
with increased risk on mental health symptoms and
mental disorders [50]. So, to develop a full picture of
the relationship between employment status and
mental health, more studies considering the quality
of employment are needed.
A third suggestion for future research would be to
investigate the role of context in the relationship
between unemployment and mental health by, for
example, examining the role that unemployment
benefits and active labour market programmes play
in this relationship.
Conclusions
This systematic review shows an existing associa-
tion between unemployment among young people
and mental health. The majority of the cross-sec-
tional studies showed that unemployment was asso-
ciated with increased mental health problems,
depression and anxiety disorders. However, whether
there is a causal relationship between unemploy-
ment at young age and mental health is less clear.
Cohort studies that did not control for confounding
factors showed an effect, but when controlling for
confounding factors, the effect reduced in most
cases and the results were mixed. When mental
health at baseline was then considered among the
confounding factors, the effect decreased in all cases
and only a minority of the studies found an effect.
To understand how much of the association between
unemployment and mental health can be consid-
ered as causation, more evidence is needed. In par-
ticular, natural experiments and longitudinal studies
that control for confounding variables could pro-
vide more definite evidence.
Authors’ Note
Vicky H. M. Bartelink is also affiliated with
Centre for epidemiology and community medicine,
Stockholm county council, Stockholm, Sweden.
Acknowledgements
The authors would like to thank the Public Health
Agency of Sweden for providing the conditions to
make this study possible.
Conflict of interest
The authors declare that there is no conflict of
interest.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-for
-profit sectors.
14    V Bartelink et al.
ORCID iD
Vicky H. M. Bartelink https://orcid.org/0000
-0001-7899-2490
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