Table 1.

Summary of included articles (N = 13).

Authors (Year)	Recession Period	Study Population	Methodology	Key Findings
Antunes, Frasquilho, Zózimo, et al. (2019) [13]	The 2008 financial crisis; the Great Recession (Portugal)	Healthcare professionals (HCP) (N = 27) and patients at primary health centers (N = 26) in Lisbon, Portugal.	Twenty-seven 27 semi-structured interviews with HCPs and five patient focus groups	Focused on solutions to address consequences of the economic recession and subsequent austerity measures. Patients suggested improvement in access, management, and efficiency of health services; social, economic, and living conditions through job availability and better salaries; investment in and recruitment of human resources for healthcare provision; investment in and promotion of mental health care. HCPs suggested improvement in integration, articulation, and coordination of health services; access to and delivery and quality of primary care services; investment in mental health professionals and improved working conditions within the health sector and social, economic, and living conditions through reversal of austerity measures.
Antunes, Frasquilho, Zózimo, et al. (2020) [14]	The 2008 financial crisis and ensuing Great Recession (Portugal)	HCPs (N = 27) and patients at primary health centers (N = 26) in Lisbon, Portugal.	Twenty-seven semi-structured interviews with HCPs and five patient focus groups	Participants saw changes in socioeconomic conditions (unemployment, precarious work conditions, and loss of income) as risk factors for poor mental health (depression, anxiety, sadness, anger, and irritability) mediated by financial hardship and deterioration of family relationships and environment. The return of young adults to their parents’ home because of worsening socioeconomic conditions contributed to parents’ financial hardship. Consequences of experiencing mental health problems during the recession (e.g., disability, sick leave, and early retirement) were perceived to occur more frequently among those who were more socially disadvantaged.
Barnes, Gunnell, Davies, et al. (2016) [15]	The 2007 to 2012 economic recession (United Kingdom (UK))	Patients who had self-harmed and attended hospital in two UK cities between December 2012 and March 2014 (N = 19).	Nineteen in-depth, semi-structured interviews	For many the self-harm episode was precipitated by issues related to the recession, such as losing or being unable to find work, fears or experiences of benefits changes or sanctions, increasing debt and housing difficulties, such as threat of eviction. All participants described other contributors to their despair, which became more salient during the hardships; for example, childhood abuse or neglect, bullying, sexual identity issues, abusive adult relationships, significant bereavements, and longstanding mental health problems. Participants expressed the desire for practical help with their economic difficulties and therapeutic support for co-existing or historical problems.
Barnes, Donovan, Wilson, et al. (2017) [16]	The 2007 to 2012 economic recession (UK)	Three study populations in two UK cities from Sept 2012 to Jan 2015: front-line staff at health and social service organizations (N = 27), individuals who self-reported problems secondary to the recession and who either had (N = 19) or had not self-harmed (N = 22).	Fifteen interviews and two focus groups with front-life staff; 17 interviews and 1 focus group with the community sample, and 19 interviews with individuals who had self-harmed.	Most participants found accessing health and social services could be difficult. Free debt advice was considered the most useful service. The community sample reported more knowledge of how to access debt advice than the patient sample, although both groups had sought similar types of help. Participants who had self-harmed reported fewer sources of support and less supportive social networks than the community sample. They also reported more difficult economic circumstances, such as benefit changes or sanctions. All groups indicated that practical help for financial and benefit issues would have helped/would help, particularly the patient group. All groups wanted straightforward information about available social and mental health services and how to access them, as well as coordination between services. Participants who had self-harmed had a stronger belief that they should be self-reliant in the face of economic and mental health difficulties than the community sample.
Bartfay, Bartfay, and Wu (2013) [17]	The 2008–2009 global economic recession (Canada)	Laid-off blue-collar autoworkers in Durham Region, Ontario, Canada between September and November 2009 (N = 34).	Participants completed a quantitative questionnaire (demographics and financials), followed by semi-structured focus groups with 4–6 participants per group.	All participants reported a high degree of stress, anxiety, or depression. More than half (55.9%) expressed concerns about the lack of mental health resources in their community; 29.4% of participants reported altered sexual function and intimacy due to emotional stress, as well as problems sleeping; 70.6% reported difficulty with effectively managing occupation-related chronic pain and discomfort. Most respondents had ceased going to complimentary healthcare providers for pain management due to financial costs (61.8%) and 32.4% reported difficulties with affording prescription medications. Notable hardships were reported for participants and their family members (38.2%), e.g., children experiencing stress, anxiety, or school problems, or loss of housing due to inability to pay rent/mortgage (21.9%).
Boycott, Akhtar, and Schneider (2015) [18]	The 2008–2009 economic recession (UK)	People with severe mental illness receiving individual placement and support (IPS) services for at least 6 months in the UK (N = 31).	Semi-structured interviews completed between July 2011 and December 2012.	Personal barriers to returning to work identified by participants included mental health symptoms, effects of medication, and disclosure of their mental health history to employers. Overall, the concerns expressed by participants did not differ substantially from those reported in papers where the wider economic situation was less bleak. The most notable differences identified were challenges with competition for jobs or lack of jobs available given the difficult economic times.
Cervero-Liceras, McKee, and Legido-Quigley (2015) [19]	The 2008–2009 European financial crisis (Spain)	Nurses (N = 5) and doctors (N = 16) across specialties in both urban and rural areas in Spain.	Semi-structured face to face interviews between May–June 2013.	The impact of financial crisis and austerity measures were observed by most HCP participants to generate an increase in levels of anxiety and depression with negative repercussions for existing physical ailments and increasing psychosomatic problems. An increase in suicides was reported. Some patients were suffering health problems due to increased caregiving burden. Healthcare workforces were affected by cuts in the number and working hours of staff, forced retirements, wage reductions, stricter control of sick leave, reduced funds for research, inappropriate use of resident trainees, and increases in wait times and overcrowding of hospitals.
Elliott, Naphan, and Kohlenberg (2015) [20]	The 2007–2008 financial crisis in Nevada, United States of America (USA)	Adults 18 or older hospitalized for actual or threatened self-harm, with or without the intent to die at a state-funded hospital (N = 16).	In-depth, semi-structured interviews conducted in 2007.	Participants reported deep disappointment with others (n = 12), extreme financial strain (n = 8), and lack of mental health care or medications (n = 8) as precipitants of their suicidal behavior. All reported economic hardship that they blamed upon themselves; 94% were unemployed at the time of hospitalization, 69% had unstable living situations, 50% were living with and dependent on others, 25% were evicted from their apartments or had their homes foreclosed. All expressed feeling inadequate about their life circumstances and blamed themselves for their situations. For 9 of 12 participants who attempted suicide, interpersonal problems that precipitated their attempts seemed to improve with hospitalization, although none of the participants said they engaged in suicidal behavior with the intent of receiving care.
Fenge, Hean, Worswick, et al. (2012) [21]	The 2007–2008 global economic recession (UK)	Older adults (65 or older) who are ‘asset-rich–income-poor’ living in the UK (N = 28).	In-depth, semi-structured interviews conducted between September 2010 and January 2011.	Extra financial demands from the recession, due to rising prices and reduced incomes, resulting in worry and stress. Linked to the fear of debt and a reluctance to borrow money, as well as worries about coping in the future. Anxiety about finances means that older people re-consider what lifestyle they can afford, reducing social activities because of the expense, ultimately impacting social well-being, increasing loneliness and isolation. In addition, declining health leads to increased costs for services and reduced mobility, which can lead to increased transport costs and social isolation.
Frasquilho, Gaspar de Matos, Santos, et al. (2016) [22]	The 2013 economic recession (Portugal)	Unemployed adults receiving state unemployment benefits with children 10 to 19 years old in Lisbon, Portugal (N = 59).	Questionnaire: demographic data, employment history, and an open-ended question on changes in family life because of unemployment.	Unemployment was seen as a source of economic hardship and pressure, requiring the household to cut down on essential needs (house, food, health), children’s education costs, and family leisure activities. Family relations were negatively affected, resulting in more friction, conflicts, and harsher parenting. Positive changes including more proximity and support were also reported. All participants’ felt unemployment was a source of psychological distress and low well-being, with increased worry, anger, bad temper, and sadness. Youth well-being was less stated, but some participants did perceive increased levels of sadness, worry, and bad temper in their children following parents’ unemployment.
Giuntoli, Hughes, Karban, and South (2015) [23]	The 2008–2010 economic recession (North England)	Adults in Bradford, England who lost their jobs between July 2008 and October 2010, presumably secondary to the economic downturn at that time (N = 73).	Basic health questionnaire and 16 focus groups were conducted with participants between July to October 2010.	Involuntary unemployment was experienced as a divestment passage for all study participants with themes emerging of: reduced agency related to financial strain and difficulties in finding a new job; disruption of role-based identities related to personal identity crises and loss of time structure and motivation; and experiences of ‘spoiled identities’ related to unemployment stigma and welfare stigma. Reduced agency was felt as a diminished capacity to pursue one’s goals and plans. Disruption of role-based identities had an immediate effect on the participants’ hedonic and psychological well-being, particularly in the form of negative evaluations of self-realization. Unemployment stigma was primarily felt in the context of family relationships, primarily through self-stigma rather than experiences of direct discrimination.
Hiswåls, Marttila, Mälstam, et al. (2017) [24]	The 2008 economic recession (Sweden)	Adults (18+ years) in Gävle, Sweden registered at an employment agency having become involuntarily unemployed for at least six months during or after 2008 (N = 16).	In-depth, semi-structured interviews.	Respondents described work as an important part of identity and the basis for belonging. A poorer financial situation was described as touch to deal with, creating worry, stress, and insecurity. This contributed to feelings of alienation and inadequacy impacting social life and consumption patterns. Therefore, this led to social isolation, which then reinforced emotions of worthlessness and shame and reduced the chances of establishing new contacts and connections that could lead to a job. Problems with sleep and progressive pain were triggered by hopelessness, fear, and anxiety. Respondents who initially saw unemployment as a positive or remained optimistic became more hopeless and uncertain as the duration of unemployment continued. Activities, structure, and affiliation in other contexts (e.g., exercise, activities that give meaning and purpose) were seen as their best coping resourced against poor mental health and a pathway towards reintegration into the job market.
Ronda, Briones-Vozmediano, Galon, et al. (2015) [25]	The 2009 economic recession (Spain)	Immigrant workers from Colombia, Ecuador, Morocco, and Romania living in Madrid, Spain between February and March of 2012 (N = 44).	Six focus group discussions were held with participants in each group of the same sex and country of origin (Colombia, Ecuador, or Spain) and two key informant interviews were held with a man and woman from Romania.	During the crisis, employment opportunities were significantly reduced for men more so than women, leaving female workers to compensate for their partners’ lack of income. However, the working conditions of remaining employment also deteriorated with more temporary contracts and reduced hours, wages, and occupational health and safety protection. Participants experienced deterioration in their quality of life as a result, leading to increased stress and depression related to worries about unemployment, lower income, and debts. Frustration was felt because of limited opportunities to improve their situation and the possibility of having to relocate or return to their country of origin. Pressure and distress were associated with diffuse pain, headaches and gastric discomfort, poorer sleep, and worsening dietary habits. Family life was negatively affected by imbalanced earning between partners, leading some to marital crises, sexual problems, and relationship breakdowns. Children’s quality of life was also felt to be negatively affected. Many had worries about economic dependants in their countries of origin that provoked personal crises in immigrants’ family relationships.