ARTICLE IN PRESS

Social Science & Medicine 60 (2005) 205218

Business cycles and mortality: results from Swedish microdata

Ulf-G. Gerdthama,b,*, Magnus Johannessonc
a
b

Department of Community Medicine, Lund University, Malmo University Hospital, SE-205 02 Malmo, Sweden
Lund University Centre for Health Economics (LUCHE), Lund University, Box 705, SE-220 07 Lund, Sweden
c
Department of Economics, Stockholm School of Economics, Box 6501, SE-113 83 Stockholm, Sweden
Available online 19 June 2004

Abstract
We assess the relationship between business cycles and mortality risk using a large individual level data set on over
40,000 individuals in Sweden who were followed for 1016 years (leading to over 500,000 person-year observations). We
test the effect of six alternative business cycle indicators on the mortality risk: the unemployment rate, the notication
rate, the deviation from the GDP trend, the GDP change, the industry capacity utilization, and the industry condence
indicator. For men we nd a signicant countercyclical relationship between the business cycle and the mortality risk
for four of the indicators and a non-signicant effect for the other two indicators. For women we cannot reject the null
hypothesis of no effect for any of the business cycle indicators.
r 2004 Elsevier Ltd. All rights reserved.
JEL classification: I12; E32
Keywords: Business cycles; Mortality; Health; Sweden

Introduction
It is controversial whether the cyclical variations in
economic activity affect mortality. Early work by
Brenner (1975, 1979) using aggregate time-series data
suggested a countercyclical relationship between business cycles and mortality, but these results were heavily
criticized on statistical grounds (Gravelle, Hutchinson,
& Stern, 1981; Wagstaff, 1985). Using cross-sectional
data for regions in Britain Junankar (1991) also found a
countercyclical relationship. In a recent contribution
Ruhm (2000) combined aggregated time-series and
cross-sectional data for US states for the 19721991
period to better control for omitted variables bias. The
unemployment rate was used as a proxy for the business
*Corresponding author. Department of Community Medicine, Lund University, Malmo University Hospital, SE-205 02
Malmo, Sweden. Tel.: +46-40-33-1969; fax: +46-4033-6215.
E-mail addresses: ulf.gerdtham@smi.mas.lu.se
(U.-G. Gerdtham), hemj@hhs.se (M. Johannesson).

cycle and a procyclical relationship between the business

cycle and mortality was found, interpreted as evidence
for that health improves during recessions. In examining
different causes of death Ruhm (2000) also found the
same procyclical variation for eight out of ten causes of
death; with suicides being an exception and exhibiting
the reversed pattern.
Gerdtham and Ruhm (2002) found similar results
using aggregate cross-country data for member nations
of the Organization for Economic Cooperation and
Development (OECD). Neumayer (2004) analysed the
effect of state unemployment and economic growth rates
on mortality in German states 19802000. Consistent
with Ruhm (2000) he found that a higher unemployment
rate was associated with lower mortality, and this
pattern was also observed for most of the causes of
death analysed.
In principle it is possible that the mortality could
decrease in recessions. The decreased economic activity
during a recession could be expected to decrease the
number of work-related injuries and the number of

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2004.05.004

ARTICLE IN PRESS
206

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

trafc accidents, although only about 5% of deaths in

the US are caused by accidents and motor vehicle
accidents (Ruhm, 2000).1 In theory it is also possible
that recessions could be health enhancing by increasing
the amount of non-market leisure time used in the
production of health, i.e. it may be less costly for
individuals to undertake time-intensive health-producing activities such as exercise during recessions (Grossman, 1972). Interestingly, however, the negative
association between unemployment and mortality in
the analysis by Ruhm (2000) was observed also in the
post-retirement age-group (65 years and older).
The above arguments could be used to support a story
for why recessions are good for health, but there are also
a number of potentially harmful effects of recessions.
Recessions may be associated with increased psychosocial stress leading to disease, due to for instance an
increased fear of losing the job (Ferrie, Shipley,
Marmot, Stansfeld, & Smith, 1995). Recessions also
increase the unemployment rate and several studies in
the public health eld suggest that unemployment may
be a health hazard (for an overview of these studies see
Jin, Shah, & Svoboda, 1995; Dooley, Fielding, & Levi,
1996, and Mathers & Schoeld, 1998). Consistent with
this is also the literature on unemployment and
happiness in economics, where several studies suggest
that unemployment leads to a reduction in happiness
and general well-being (Clark & Oswald, 1994; Winkelmann & Winkelmann, 1998; Theodossiou, 1998).
Recessions are also associated with relatively lower
income levels, and to the extent that transitory income
changes affect consumption, this may lead to a
deterioration of health. It is relatively well established
that there is a causal protective effect of income on
health (Viscusi, 1994a, b; Lutter & Morrall, 1994;
Lutter, Morrall, & Viscusi 1999; Smith, 1999; Gerdtham
& Johannesson, 2002, 2004).
The net effect of recessions on mortality is an open
empirical question. A problem in using aggregated data
is that it leads to difculties in inferring causation
between variables. It is therefore interesting to test the
effect of business cycles on mortality also with individual
level data. In a recent study Ruhm (2003) also uses
microdata to assess the relationship between business
cycles (measured as the unemployment rate) and
individual level survey data on health status (e.g. the
probability of reporting one or more medical problems
and the number of reported restricted-activity days).
Consistent with his aggregated data results he nds that
health status increases during recessions.
In this paper, we use individual level data to estimate
the relationship between business cycles and mortality.
We use a large data set on over 40,000 individuals aged
1
In our data for Sweden 2.5% of deaths were caused by
accidents and motor vehicle accidents.

1684 years who were interviewed as part of a general

population survey in Sweden 19801986. These individuals are followed-up with respect to mortality until the
end of 1996, creating a data set of over 500,000 personyear observations on mortality. Using these data, we test
if the annual mortality risk is related to the business
cycle, using probit models. Because it is not obvious how
to measure the business cycle we use six alternative
indicators of economic activity: the unemployment rate,
the notication rate, the deviation from the GDP (Gross
Domestic Product) trend, the GDP change, the industry
capacity utilization, and the industry condence indicator. For men we nd a signicant countercyclical
relationship between business cycles and the mortality
risk for four of the indicators and a non-signicant effect
for the other two indicators. For women we cannot
reject the null hypothesis of no effect for any of the
business cycle indicators. In relative terms the countercyclical effect for men is strongest for suicides. Our
results suggest that recessions increase the mortality risk
of men, but have no effect on the mortality of women.

Data and methods

Data and variables
The analysis is based on data from Statistic Swedens
Survey of Living Conditions (the ULF survey) (Statistics
Sweden, 1997), which have been linked to mortality data
from the National Causes of Death Statistics that
registers all deaths of individuals registered as living in
Sweden. Since 1975, Statistics Sweden conducts annual
surveys of living conditions in the form of 1-h personal
interviews with randomly selected adults aged 1684
years. In this paper, we use pooled data from a set of
initial interviews conducted from 1980 to 1986. The total
sample consists of 47,484 individuals who were interviewed during this 7-year period. The mortality experience of the sample was recorded until 31 December
1996. Based on this data we create a data set of annual
observations on mortality, to test if the mortality risk in
a year is related to the business cycle in that year. For
each individual that survives during the entire follow-up
we get between 10 (if interviewed in 1986) and 16 (if
interviewed in 1980) person-year observations.2 This
gives us a data set of 539,750 person-year observations.
The dichotomous-dependent variable in the regression
analysis is whether the individual died (=1) or not (=0)
2
The interview year of the individual is not included as an
observation, because individuals are not observed during the
entire interview year (the length of observation in the interview
year depends on the date of the interview that varies between
individuals). The rst annual observation for an individual
interviewed in 1980 is therefore 1981.

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U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

during the observation year. The total number of deaths

in the data set is 6571. To test if the mortality risk is
related to the business cycle we estimate the following
model:
Pit a b1 AGEit b2 BCt b3 t eit ;

where Pit is the probability of dying for individual i in

year t: AGEit is the age of subject i in year t; BCt is the
business cycle in year t; t is the year of the observation,
and e is the error term. The age variable control for the
difference in age between individuals and the time trend
variable measures the trend in mortality over time (i.e.
the difference in mortality risk between cohorts). The
business cycle variable tests if the deviation from the
trend in mortality is related to the business cycle.
The mean age at the interview year is 45.9 years, and
the mean age for all the person-year observations is 48.8
years. Separate analyses are carried out for men and
women, because the effect of the business cycle on
mortality may differ for men and women. The fraction of
men in the study is 0.49, and the number of person-year
observations is 264,744 for men and 275,006 for women.
Because it is not obvious how to measure business cycles,
we include six different indicator variables to test if the
results are sensitive to the measure used.
Most previous studies have used the unemployment
rate as the business cycle indicator. We also include this
variable, estimated as the ratio between unemployed
persons and the total number of persons in the labour
force (mean 4.22%, STD 2.58%).3 A drawback of the
unemployment variable is that it does not take into
account changes in the labour force and government
sponsored labour market policy programs.4 Unemployment measures are also imperfect measures of the
business cycle, due to possible time lags between the
business cycle and employment (i.e. it may take some time
before a downturn in the economy affects employment).5
3

In Sweden a person is dened as being unemployed if he/she

is out of work but would like to work and has actively been
seeking employment during the last 4 weeks.
4
We also tested using the employment rate, estimated as the
ratio between employed persons and the total number of
persons 1664 years old (mean 78.29%, STD 4.28%). This led
to almost identical results as using the unemployment rate, and
the results are therefore not reported.
5
Even if the unemployment rate is a poor measure of the
business cycle it might as pointed out by an anonymous referee
be a good measure of a different aspect of the labour market.
The unemployment rate is probably the most publicly reported
and therefore best known of the six business cycles indicators in
our study. When there is high perceived unemployment,
unemployed people may be able to attribute their employment
problems to external factors thus relieving themselves of some
responsibility or guilt. Also, high unemployment might make
those in otherwise unpleasant jobs more content with their
relatively advantaged situations.

207

A labour market measure that does not suffer from this

problem is advanced notications of job loss (i.e.
workers who receive advance notice of impending
dismissal from their jobs). The Promotion of Employment Act in Sweden stipulates a mandatory notice
period for employers ranging from 2 to 6 months
depending on the number of dismissals (Jans, 2002).
Most workers are also covered by collective agreements
made by the unions offering longer notice periods (Jans,
2002). We use the notication rate estimated as the ratio
between notied workers and the total number of
persons in the labour force (mean 1.41%, STD 1.13%)
as one of our business cycle indicators (Jans, 2002).
A natural measure of the business cycle is to measure
the GDP. In the macroliterature it is common to use
either the change in GDP or the deviation from the
trend in GDP as a measure of the business cycle
(Kydland & Prescott, 1982; Hall, 1988; King & Rebelo,
1993; Gali, 1999). We use both these measures (mean
GDP change 1.68%, STD 2.00%). We measure the
trend based on yearly observations between 1970 and
2000, and a constant growth rate is assumed (Kydland &
Prescott, 1982; King & Rebelo, 1993). The percentage
deviation from this trend is used as the business cycle
indicator (mean 0.002%, STD 0.032%).
Another potential measure of economic activity is the
degree of capacity utilization in the industry. We use the
measure collected by Statistics Sweden for manufacturing, mining and quarrying (mean 86.51%, STD 2.69%).
Finally, we use a measure called the condence indicator
for the manufacturing industry (mean 11.44, STD
15.09). This measure is part of the Business Tendency
Survey carried out by the National Institute of
Economic Research. The Business Tendency Survey is
intended to provide a quick qualitative indication of
actual outcomes and expectations regarding central
economic variables for which no quantitative information is yet available. The condence indicator is based
on the proportion of rms reporting positive/negative
changes on three survey indicators (assessment of the
order-book, assessment of the stock of nished goods,
and the expected production).6 Similar business tendency surveys are carried out in all EU member states.
We use data from the quarterly Business Tendency
Survey and estimate the annual condence indicator as
the average for the four quarters. Annual data on
unemployment and GDP and quarterly data on the
condence indicator was downloaded from the home6

The condence indicator is obtained by adding the

proportions of rms reporting positive changes on the three
questions and deducting the proportion of rms reporting
negative changes. The average for the condence indicator
during the period 19642001 is 10 (and there is no trend in the
condence indicator over time), indicating that on average the
rms are overly pessimistic.

ARTICLE IN PRESS

Descriptives and correlations

In Table 1 we show the correlation between the six
business cycle indicators for the period 19811996. The
unemployment rate is highly correlated with the deviation from the trend in GDP, but is not signicantly
correlated with any of the other business cycle indicators. The change in GDP, the capacity utilization and
the condence indicator are highly correlated with each
other, but only moderately correlated with the deviation
from the trend in GDP. The notication rate is highly
correlated with the GDP change and the condence
indicator and moderately correlated with the other

(0.086)
(0.510)
(0.461)
(0.552)
(0.308)
(0.786)
0.443
0.178
0.198
0.161
0.272
0.074
0.456 (0.076)
0.119 (0.660)
0.813 (0.000)
0.654 (0.006)
0.080 (0.768)
0.375 (0.153)
0.124 (0.648)
0.867 (0.000)
0.630 (0.009)
0.804 (0.000)
0.343 (0.194)
1.000
0.815 (0.000)
0.452 (0.079)
0.478 (0.061)
0.216 (0.422)
1.000
0.343 (0.194)
0.147 (0.587)
0.703 (0.002)
0.796 (0.000)
1.000
0.216 (0.422)
0.804 (0.000)

Condence
indicator
Capacity
utilization

0.066 (0.807)
0.548 (0.028)
1.000
0.796 (0.000)
0.478 (0.061)
0.630 (0.009)
p-values within parentheses.
 po0:05

Results

Notication rate

where Dit is a dummy variable talking the value 1 if

individual i dies in year t and the value 0 if the individual
survives. b0 xit is the predictor of the probability of dying
in year t; Fb0 xit ; for an individual with the characteristic vector xit : F : is the cumulative density function
which is taken to be normal in the probit model.
Estimation is undertaken by maximum likelihood
methods, and to take into account the panel nature of
the data the standard errors and t-ratios of coefcients are estimated using the Huber/White/sandwich
estimator of variance and clustering on individuals
(Guilkey & Murphy, 1993). This simple approach to
account for the correlation between observations within
individuals in a probit model was recommended by
Guilkey and Murphy (1993). In a sensitivity analysis we
also use a random effects probit model and a random
effects logit model.
For all three variables (age, time trend, and business
cycle indicator) we include the variable and the square of
the variable to allow for a exible functional form. The
squared terms are only included in the nal model if they
are signicant. All tests of statistical signicance are
carried out at the 5% level.

Deviation from
GDP trend

PrDit 0 1  F b0 xit ;

Table 1
Bivariate correlations between business cycle indicators

PrDit 1 F b0 xit ;

GDP change

To econometrically estimate Eq. (1) we estimate a

probit model of the annual mortality risk (Greene,
2000). Following standard econometrics, a probit likelihood function of being dead is derived as follows:
Y
Lb
F b0 xit Dit 1  F b0 xit 1Dit ;

0.316 (0.233)
1.000
0.548 (0.028)
0.703 (0.002)
0.452 (0.079)
0.867 (0.000)

Estimation

1.000
0.316 (0.233)
0.066 (0.807)
0.147 (0.587)
0.815 (0.000)
0.124 (0.648)

Male annual
mortality risk

page of the National Institute of Economic Research

(www.konj.se). The annual data on industry capacity
utilization was supplied by Statistics Sweden and the
Swedish National Labour Market Board supplied the
annual data on notications.

Unemploy-ment rate
Notication rate
Capacity utilization
Condence indicator
Deviation from GDP trend
GDP change

Female annual
mortality risk

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

Unemploy-ment
rate

208

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U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

measures. That the measures are not perfectly correlated

suggest that the results may be sensitive towards the
business cycle indicator used.
In Figs. 1 (men) and 2 (women) we plot the variation
in the annual mortality risk over time and three of the
business cycle indicators (the unemployment rate, the
capacity utilization, and the GDP change). The annual
mortality risk is derived from a probit model with year
dummy variables, controlling for age and the square of
age. The age is held constant at the mean age at the
interview year, to measure the variation in the mortality
risk over time controlling for age. In Table 1 we also
show the correlation between the annual mortality risk
for men and women and each of the business cycle
indicators.
The graph for the unemployment rate shows that the
unemployment rate increased greatly between 1990 and
1993 (to 8.2% in 1993) during the recession in the early
nineties. Although the economy subsequently improved
as can be seen from the other indicators, the unemployment rate did not come down, but was still 8.1% in
1996. This suggests that the unemployment rate may not
be a good indicator of the business cycle in Sweden for
our studied time period. This is also indicated by the low
correlations of the unemployment rate with the other
business cycle indicators (except the deviation from the
GDP trend). There is a negative correlation between the
mortality risk for men and women and the unemployment rate for the entire period. However, if the period is
restricted to 19811991 (before the leap in the unem6
4
2
0
-2
-4
-6
1981

1983

1985
Male

1987

Unemrate

1989

1991

Capacity utilization

1993

1995

GDP change

Fig. 1. The male mortality risk and the unemployment rate

(unemrate), capacity utilization, GDP change 19811996 (in
standard deviations from mean).

6
4
2
0
-2
-4
-6
1981

1986
Female

Unemrate

1991
Capacity utilization

1996
GDP change

Fig. 2. The female mortality risk and the unemployment rate

(unemrate), capacity utilization, GDP change 19811996 (in
standard deviations from mean).

209

ployment rate), the correlation is highly positive for men

(0.47) and about zero for women (0.029). This sensitivity
to the studied time period reinforces the problem noted
above of using the unemployment rate as a business
cycle indicator. This problem is further addressed in the
sensitivity analysis below.
Interestingly the peak in the notication rate occurred
one year before (1992) the peak in the unemployment
rate, and the notication rate then returned to a more
normal level in 1994. The correlation between the
notication rate and the mortality risk is positive for
men and negative for women. But the correlations are
low and non-signicant.
The graph for the capacity utilization show that the
mortality risk for men seem to vary countercyclically
with the business cycle, whereas the correlations are
low for women. The results are similar for the
condence indicator. The same pattern is also observed
for the GDP change, although the correlations are
weaker. The deviation in the GDP trend is not strongly
correlated with the mortality risk for either men or
women.
Regression results
In Table 2 we show the regression results for men. The
unemployment variable has a negative sign, but is far
from being signicant. The notication rate has a
positive sign and the effect is highly signicant,
suggesting a countercyclical relationship between the
business cycle and mortality.7 Also the capacity utilization, the condence indicator and the GDP change are
highly signicant, with a countercyclical relationship
between business cycles and mortality. The nal
indicator, the deviation from the GDP trend, also
suggests that the mortality risk increases in recessions,
but the effect is not signicant.8
To estimate the size of the effect of the signicant
business cycle indicators on mortality, we estimate the
effect on mortality of a standard deviation improvement
in the business cycle. Evaluated at the mean of the
covariates a standard deviation decrease in the notication rate decreases the annual mortality risk by 6.8%
(from 0.51% to 0.48%), a standard deviation increase in
7
It may appear inconsistent that the notication rate now is
highly signicant, when the correlation was low and insignificant in Table 1. The difference in results depends on that we
control for the time trend in mortality in the regression results,
which was not done in the correlations in Table 1. If the time
trend is not controlled for, the notication rate is not signicant
in the regression equation consistent with Table 1.
8
We also tested including all six business cycle indicators in
the same regression equation; but this led to problems with
multicollinearity as some of the indicators are highly correlated
(and none of the indicators were statistically signicant in this
regression equation).

ARTICLE IN PRESS

0.2050
0.2047
0.2047

Constant
Age
Age squared
Business cycle indicator
Time trend
Number of observations
Log-Likelihood
Wald w2 test of all
coefcients=0
Pseudo R2

All cause mortality risk for MEN. Number of obs=264 744. t-ratios within parentheses (robust standard errors adjusted for clustering on individuals).
 po0:05:

0.2051
0.2047
0.2051
0.2050

3.26859 (28.85)
0.00451 (1.23)
0.00036 (12.34)
0.26527 (1.00)
0.00891 (4.03)
264744
15460.611
6066.36
3.30529 (29.18)
0.00450 (1.23)
0.00036 (12.33)
0.00190 (3.91)
0.00756 (3.93)
264744
15453.498
6091.78
2.43411 (9.21)
0.00450 (1.22)
0.00036 (12.34)
0.00993 (3.53)
0.00657 (3.39)
264744
15454.977
6075.02
3.27990 (29.05)
0.00449 (1.22)
0.00036 (12.33)
0.00060 (0.13)
0.00753 (2.46)
264744
15461.123
6078.70
3.27942 (29.08)
0.00449 (1.22)
0.00036 (12.33)

0.00784 (4.08)
264744
15461.132
6075.28

3.28987 (29.11)
0.00446 (1.22)
0.00036 (12.31)
0.02134 (3.19)
0.01005 (4.88)
264744
15456.156
6094.11

GDP change
Deviation from
GDP trend
Capacity utilization Condence
indicator
Unemployment rate Notication rate
No business cycle
indicator
Covariate

Table 2
Probit estimation results

3.24055 (28.53)
0.00444 (1.21)
0.00036 (12.31)
0.01434 (3.85)
0.00964 (4.82)
264744
15453.817
6098.96

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

210

capacity utilization decreases the annual mortality risk

by 7.4%, a standard deviation increase in the condence
indicator decreases the mortality risk by 8.0%, and a
standard deviation increase in the GDP change
decreases the mortality risk by 8.0%.
In Table 3 we show the regression results for women.
For women none of the business cycle indicators are
signicant, and we cannot reject the null hypothesis of
no effect of business cycles on the female mortality risk.9
The square of the time trend is not signicant for any
of the regression models in Tables 2 and 3, and is
therefore not included in the tables. To further test the
functional form of the time trend we also test adding
both the square and the cube of the time trend.
Including this more exible functional form of the time
trend has little effect on the results. For women all the
six business cycle indicators are still insignicant, and
the square and cube of the time trend are not signicant
in any of the six regression equations. For men the
results are similar to those in Table 2, with the
difference that the notication rate (p 0:076) and
the capacity utilization (p 0:051) are not signicant at
the 5% level. The square and cube of the time trend are
only signicant in the regression equations with
unemployment and the deviation from the GDP
trend (and in these two cases the business cycle
indicators are not signicant, consistent with the results
in Table 2).
Sensitivity analysis
To test the stability of the results we carry out an
extensive sensitivity analysis that covers the following
issues: the time period of the analysis, the variables
included and the estimation method, age groups, cause
specic mortality, and time lags. The results of the
sensitivity analysis are shown in Tables 4 (men) and 5
(women). In all the sensitivity analyses age, the square of
age, and the time trend are included as independent
variables (but the coefcients of these variables are not
shown in Tables 4 and 5). The effect of the business cycle
indicators are not signicant in any of the sensitivity
analyses for women (with two exceptions mentioned
below), and in the text below we therefore concentrate
on the results for men.
Time period
A problem in the analysis with the unemployment rate
is that as can be seen in Fig. 1, the unemployment level
increased in the early 1990s. The unemployment rate
9

We also test using the unemployment rate for men in the

regression analysis for men and the unemployment rate for
women in the regression analysis for women, rather than the
overall unemployment rate. This leads to very similar results as
using the overall unemployment rate.

ARTICLE IN PRESS

All cause mortality risk for WOMEN. Number of obs=275 006. t-Ratios within parentheses (robust standard errors adjusted for clustering on individuals).
 po0:05:

0.2049
0.2050

Constant
Age
Age squared
Business cycle indicator
Time trend
Number of observations
Log-likelihood
Wald w2 test of all
coefcients=0
Pseudo R2

0.2049
0.2050
0.2049

0.2049

0.2049

3.32488 (29.56)
0.00968 (2.70)
0.00039 (12.72)
0.00037 (0.09)
0.00565 (2.60)
275006
12713.208
4754.23
3.34245 (29.73)
0.00971 (2.71)
0.00039 (13.72)
0.39327 (1.34)
0.00384 (1.52)
275006
12712.287
4776.63
3.32666 (29.74)
0.00968 (2.70)
0.00039 (13.72)
0.00006 (0.10)
0.00559 (2.63)
275713.207
12688.722
4754.26
3.44820 (11.74)
0.00968 (2.70)
0.00039 (12.72)
0.00143 (0.45)
0.00577 (2.68)
275006
12713.109
4755.56
3.33209 (29.78)
0.00972 (2.71)
0.00039 (13.72)
0.00756 (1.54)
0.00149 (0.43)
275006
12711.998
4782.46
3.32592 (29.78)
0.00968 (2.70)
0.00039 (12.72)

0.00560 (2.64)
2750064
12713.212
4753.66

3.32468 (29.76)
0.00968 (2.70)
0.00039 (13.72)
0.00279 (0.38)
0.00533 (2.38)
275006
12713.141
4753.15

Unemployment rate Notication rate

No business cycle
indicator
Covariate

Table 3
Probit estimation results

Capacity utilization Condence

indicator

Deviation from
GDP trend

GDP change

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

211

may thus be correlated with the time trend, causing a

potential bias. The direction of this bias will be towards
nding a spurious protective effect of unemployment. To
test for this problem we exclude the 19931996, 1992
1996, and 19911996 periods, respectively.10 When we
exclude these years for men the effect of the unemployment variable is reversed consistent with the results for
the other business cycle indicators. But the unemployment variable is not signicant for any of the time
periods. For the other business cycle indicators the results
are similar to the baseline results, with the difference that
also the deviation from the trend in GDP is signicant.
Due to the sensitivity of the time period used in the
analyses for the unemployment rate, we present the
results for both the entire time period (19811996) and
the time period 19811991 in the remaining sensitivity
analyses. To do the remaining sensitivity analysis for the
two different time periods also works as an additional
stability test of the results.
Variables and estimation
We test if the results change if we add controls for the
education and permanent income of the individuals.
Education is divided into four classes (pre-secondary
education, short secondary education (p2 years),
secondary education (>2 years), and university education) and permanent income is measured as the annuity
of the predicted lifetime disposable income and net
wealth per adult person in the household (see Gerdtham
& Johannesson, 2002) for details about this income
measure). Adding these variables leads to very similar
results as in the baseline analysis.
We also test including controls for geographical areas.
We include xed effects for counties (Sweden was
divided into 24 counties at the time of this study) in
one analysis and xed effects for counties and county
specic time trends in one analysis. This has little effect
on the results.
In another sensitivity analysis we use a random effects
probit model and a random effects logit model to
account for the potential correlation between observations over time on the same person (instead of using
robust standard errors adjusted for clustering on
individuals as in the baseline analysis). This also has
little effect on the results.
Age groups
It is also interesting to investigate if the effect of the
business cycle differs between young and old, and we
therefore reestimate our results for two separate age
groups (1664 years of age and X65years). For men the
10
As can be seen in Figs. 1 and 2 it is difcult to see exactly at
which year the level of unemployment increased, i.e. to separate
the cyclical variations in unemployment from the increased
mean level. We therefore test excluding three time periods.

212

Table 4
Sensitivity analysis for men of the estimated coefcients of the business cycle indicators
Unemploy-ment rate

Notication rate

Capacity utilization

Condence indicator

Deviation from GDP

trend

GDP change

0.00993 (3.53)

0.00190 (3.91)

0.26527 (1.00)

0.01434 (3.85)

0.01107 (1.39)
0.02074 (1.24)
0.02159 (0.53)

0.01754 (1.97)
0.02229 (1.86)
0.09762 (2.56)

0.00847 (2.63)
0.01070 (2.64)
0.02037 (2.96)

0.00178 (2.89)
0.00178 (2.75)
0.00258 (2.80)

0.71304 (1.92)
1.28749 (2.04)
4.03830 (2.53)

0.01759 (2.74)
0.01934 (2.63)
0.02985 (2.68)

Controlling for permanent income and education

19811996
0.00089 (0.20)
19811991
0.01984 (1.19)

0.02131 (3.19)
0.02155 (1.80)

0.00987 (3.50)
0.01050 (2.59)

0.00189 (3.91)
0.00173 (2.67)

0.24880 (0.94)
1.24895 (1.97)

0.01433 (3.84)
0.01886 (2.56)

Controlling for county fixed effects

19811996
19811991

0.02152 (3.22)
0.02217 (1.85)

0.00996 (3.54)
0.01065 (2.63)

0.00191 (3.96)
0.00178 (2.74)

0.25883 (0.98)
1.27445 (0.02)

0.01439 (3.86)
0.01924 (2.62)

Controlling for county fixed effects and county specific time trends
19811996
0.00172 (0.39)
19811991
0.01786 (1.07)

0.02162 (3.23)
0.01931 (1.61)

0.00970 (3.45)
0.00951 (2.34)

0.00191 (3.94)
0.00162 (2.50)

0.20692 (0.78)
1.1301 (1.79)

0.01446 (3.88)
0.01724 (2.34)

Alternative panel data estimations

Random effects probit: 19811996
Random effects probit: 19811991
Random effects logit: 19811996
Random effects logit: 19811991

0.00060
0.02074
0.00112
0.03875

(0.14)
(1.25)
(0.11)
(1.01)

0.02134 (3.17)
0.02229 (1.86)
0.04546 (2.99)
0.04423 (1.60)

0.00993
0.01070
0.02236
0.02277

0.00190
0.00178
0.00405
0.00384

(3.91)
(2.75)
(3.66)
(2.55)

0.26527 (1.02)
1.28749 (2.04)
0.73347 (1.22)
2.58440 (1.77)

0.01434
0.01934
0.03150
0.04251

Age groups
o65 years:
o65 years:
X65 years:
X65 years:

0.00875
0.04851
0.00176
0.00605

(1.13)
(1.66)
(0.32)
(0.30)

0.03193 (2.62)
0.04266 (2.10)
0.01689 (2.11)
0.01073 (0.72)

0.01226 (2.55)
0.01727 (2.64)
0.00821 (2.36)
0.00645 (1.24)

0.00264 (2.99)
0.00223 (2.01)
0.00155 (2.68)
0.00151 (1.88)

0.06394 (0.14)
2.43914 (2.26)
0.34225 (1.05)
0.64654 (0.83)

0.01911 (2.81)
0.02506 (2.10)
0.01246 (2.78)
0.01539 (1.63)

0.00742
0.01315
0.00111
0.02285
0.00253
0.05254
0.00867
0.09391
0.00458
0.00671

(1.02)
(0.48)
(0.19)
(1.06)
(0.27)
(1.46)
(0.45)
(1.34)
(0.29)
(0.10)

0.03070 (2.87)
0.01095 (0.55)
0.01318 (1.53)
0.03019 (1.97)
0.00811 (0.59)
0.03360 (1.26)
0.05672 (2.14)
0.06355 (1.31)
0.01443 (0.56)
0.00861 (0.17)

0.00927 (1.98)
0.00264 (0.38)
0.00802 (2.19)
0.01372 (2.63)
0.00548 (0.92)
0.00212 (0.23)
0.02277 (1.95)
0.02513 (1.53)
0.00732 (0.71)
0.00083 (0.05)

0.00182 (2.28)
0.00068 (0.63)
0.00182 (2.92)
0.00239 (2.84)
0.00022 (0.22)
0.00100 (0.72)
0.00445 (2.16)
0.00278 (0.97)
0.00125 (0.71)
0.00105 (0.42)

0.00973 (0.02)
0.64820 (0.62)
0.18264 (0.52)
1.61459 (2.00)
0.01535 (0.03)
1.66043 (1.20)
0.20286 (0.18)
3.78098 (1.43)
0.28663 (0.31)
0.07441 (0.03)

0.01807 (2.97)
0.01176 (0.94)
0.01296 (2.69)
0.02848 (3.00)
0.002900 (0.38)
0.02028 (1.17)
0.03424 (2.19)
0.03134 (1.04)
0.00776 (0.59)
0.00863 (0.31)

19811996
19811991
19811996
19811991

Cause specific mortality

Cancer: 19811996
Cancer: 19811991
Cardiovascular: 19811996
Cardiovascular: 19811991
Other diseases : 19811996
Other diseases: 19811991
Suicides: 19811996
Suicides: 19811991
Other external: 19811996
Other external: 19811991

0.00074 (0.16)
0.02046 (1.22)

t-ratios within parentheses (robust standard errors adjusted for clustering on individuals).
 po0:05:

(3.52)
(2.63)
(3.45)
(2.39)

(3.83)
(2.63)
(3.71)
(2.46)

ARTICLE IN PRESS

0.02134 (3.19)

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

0.00060 (0.13)

Baseline result
Selected time periods
19811992
19811991
19811990

Table 5
Sensitivity analysis for women of the estimated coefcients of the business cycle indicators
Unemploy-ment rate

Notication rate

Capacity utilization

Condence indicator

Deviation from GDP

trend

GDP Change

0.00143 (0.45)

0.00006 (0.10)

0.39327 (1.34)

0.00037 (0.09)

0.01526 (1.71)
0.01304 (0.71)
0.00011 (0.01)

0.01365 (1.36)
0.00579 (0.43)
0.04228 (0.98)

0.00354 (0.94)
0.00002 (0.00)
0.00894 (1.10)

0.00022 (0.32)
0.00012 (0.16)
0.00103 (1.00)

0.63926 (1.53)
0.31953 (0.45)
1.20521 (0.68)

0.00533 (0.71)
0.00045 (0.05)
0.01273 (1.00)

Controlling for permanent income and education

19811996
0.00770 (1.57)
19811991
0.01372 (0.75))

0.00308 (0.42)
0.00633 (0.47)

0.00159 (0.50)
0.00019 (0.04)

0.00004 (0.07)
0.00008 (0.11)

0.40507 (1.38)
0.35028 (0.50)

0.00024 (0.06)
0.00008 (0.01)

Controlling for county fixed effects

19811996
19811991

0.00280 (0.38)
0.00537 (0.40)

0.00140 (0.44)
0.00017 (0.04)

0.00006 (0.10)
0.00013 (0.18)

0.38554 (1.32)
0.30193 (0.43)

0.00032 (0.08)
 0.00066 (0.08)

0.00271 (0.37)
0.00800 (0.59)

0.00160 (0.50)
0.00097 (0.21)

0.00005 (0.10)
0.00002 (0.02)

0.43135 (1.47)
0.42142 (0.59)

0.00041 (0.10)
0.00150 (0.18)

0.39327
0.31953
0.71932
0.82063

0.00037
0.00045
0.00087
0.00015

(0.09)
(0.05)
(0.09)
(0.01)

0.00741 (1.51)
0.01263 (0.69)

Controlling for county fixed effects and county specific time trends
19811996
0.00826 (1.68)
19811991
0.01430(0.78)
Alternative panel data estimations
Random effects probit: 19811996
Random effects probit: 19811991
Random effects logit: 19811996
Random effects logit: 19811991
Age groups
o65 years: 19811996
o65 years: 19811991
X65 years: 19811996
X65 years: 19811991
Cause specific mortality
Cancer: 19811996
Cancer: 19811991
Cardiovascular: 19811996
Cardiovascular: 19811991
Other diseases : 19811996
Other diseases: 19811991
Suicides: 19811996
Suicides: 19811991
Other external: 19811996
Other external: 19811991

0.00756
0.01304
0.01426
0.03177

0.00279
0.00579
0.00629
 0.01582

(0.38)
(0.43)
(0.36)
(0.49)

0.00143
0.00002
0.00264
0.00059

(0.45)
(0.00)
(0.35)
(0.05)

0.00006
0.00002
0.00007
0.00032

(0.11)
(0.16)
(0.05)
(0.18)

0.02327 (2.48)
0.03758 (1.03)
0.00226 (0.39)
0.00415 (0.19)

0.01435
0.03079
0.00097
0.00341

(0.88)
(1.14)
(0.12)
(0.22)

0.00919
0.00834
0.00129
0.00347

(1.42)
(0.92)
(0.35)
(0.62)

0.00110
0.00121
0.00019
0.00062

(0.31)
(0.88)
(0.32)
(0.72)

1.44329 (2.54)
1.54421 (1.09)
0.03102 (0.09)
0.12869 (0.16)

0.00629
0.01478
0.00254
0.00688

(0.77)
(0.93)
(0.55)
(0.68)

0.01709 (2.25)
0.00419 (0.15)
0.00328 (0.47)
0.02176 (0.85)
0.01912 (2.02)
0.04563 (1.24)
0.01170 (0.42)
0.06615 (0.73)
0.02598 (1.28)
0.09541 (1.23)

0.00339
0.00090
0.00085
0.00865
0.00260
0.02808
0.02156
0.06479
0.04934
0.05076

(0.29)
(0.04)
(0.09)
(0.46)
(0.18)
(1.03)
(0.54)
(1.02)
(1.37)
(0.91)

0.00090 (0.18)
0.00175(-0.24)
0.00257 (0.58)
0.00339 (0.51)
0.00711 (1.10)
0.01574 (1.51)
0.01069 (0.65)
0.02732 (1.24)
0.02647 (1.81)
0.01984 (0.97)

0.00063
0.00030
0.00033
0.00053
0.00029
0.00213
0.00174
0.00382
0.00349
0.00237

(0.75)
(0.27)
(0.45)
(0.51)
(0.28)
(1.43)
(0.53)
(0.94)
(1.43)
(0.80)

0.83432
0.09694
0.05677
0.36359
1.18473
1.96712
1.61485
3.58286
1.95808
3.40202

0.00409
0.00729
0.00392
0.00187
0.00046
0.01687
0.01071
0.04840
0.03011
0.02330

(0.66)
(0.56)
(0.71)
(0.15)
(0.06)
(0.91)
(0.45)
(1.33)
(1.69)
(0.58)

(1.56)
(0.71)
(1.23)
(0.73

(1.36)
(0.45)
(1.04)
(0.49)

(1.83)
(0.09)
(0.14)
(0.37)
(1.90)
(1.37)
(0.06)
(1.06)
(1.62)
(1.19)

t-ratios within parentheses (robust standard errors adjusted for clustering on individuals).
 po0:05:

ARTICLE IN PRESS

0.00279 (0.38)

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

0.00756 (1.54)

Baseline result
Selected time periods
19811992
19811991
19811990

213

ARTICLE IN PRESS
214

U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

four signicant business cycle indicators in the baseline

analysis are signicant in both age groups, although the
size of the coefcient is greater for working-age men
(and the effect for older men is not signicant if the time
period is restricted to 19811991). The predicted relative
risk change varies substantially between the age groups.
A standard deviation decrease in the notication rate
decreases the mortality risk by 9.5% for working-age
men and 5.3% for older men. A standard deviation
increase in capacity utilization decreases the mortality
risk by 9.9% for working-age men and 4.6% for older
men. A standard deviation increase in the condence
indicator decreases the mortality risk by 11.9% for
working-age men and 4.9% for older men. A standard
deviation increase in the GDP change decreases the
mortality risk by 11.4% for working-age men and 5.2%
for older men. The unemployment rate is not signicant
for either younger or older men, and the deviation from
the GDP trend is not signicant either (with the
exception of younger men for the time period 1981
1991).
For younger women the unemployment rate and the
deviation from the trend in GDP are signicant for the
analysis of the entire time period (with a sign suggesting
a procyclical relationship). The signicant results,
however, disappear if the analyses are carried out for
the 19811991 period.

Cause specific mortality

The analyses above are based on all-cause mortality,
but it is also interesting to test the effect of business
cycles on cause specic mortality as was done by Ruhm
(2000). A rst distinction can be made between deaths
due to diseases and deaths due to external causes. For
diseases we separated the two main causes of death:
cardiovascular (1877 deaths for men and 1347 deaths for
women) and cancer (881 deaths for men and 761 deaths
for women). The residual disease category is called
other diseases (536 deaths for men and 466 deaths for
women). Deaths due to external causes are divided into
suicides (70 deaths for men and 32 deaths for women)
and other external deaths (motor vehicle accidents,
accidents and homicides; 106 deaths for men and 68
deaths for women).11 It would also have been interesting
to analyse deaths from motor vehicle accidents separately, but that was not possible due to the low number
of deaths from motor vehicle accidents in our data (27
for men and 16 for women).
11
The classication of diseases is based on the Ninth
Revision of the International Classication of Diseases (ICD9 categories). The following classications are used: cardiovascular (390459), cancer (140239), other diseases (all disease
codes except cancer and cardiovacular), suicides (E950959),
other external deaths (E800949, E960989).

The results for cardiovascular diseases, cancer, and

suicides are consistent with the baseline results. The
notication rate, the capacity utilization, the condence
indicator and the GDP change variables are signicant
with a countercyclical effect (with the exception of the
capacity utilization for suicides that falls just outside of
the 5% signicance level, and the notication rate for
cardiovascular diseases that is not quite signicant). A
standard deviation decrease in the notication rate
decreases the cardiovascular mortality risk by 4.8%, the
cancer mortality risk by 11.1% and the risk of suicide by
21.5%. A standard deviation increase in capacity
utilization decreases the cardiovascular mortality risk
by 6.8%, the cancer mortality risk by 8.0% and the risk
of suicide by 20.6%. A standard deviation increase in
the condence indicator decreases the cardiovascular
mortality risk by 8.7%, the cancer mortality risk by
8.8% and the risk of suicide by 22.3%. A standard
deviation increase in the GDP change decreases the
cardiovascular mortality risk by 8.2%, the cancer
mortality risk by 11.4% and the risk of suicide by
22.7%.
For cardiovascular diseases the results are stable
towards limiting the time period to 19811991, whereas
for cancer and suicides none of the business cycle
indicators are signicant for the 19811991 period. The
coefcients for suicides are relatively stable in the two
time periods, whereas the absolute size of the coefcients
for cancer drops considerably if the analysis is restricted
to the 19811991 period. For the other two causes of
death (other diseases and other external) we cannot
reject the null hypothesis of no effect for any of the
business cycle indicators. It is important to bear in mind,
however, the limited statistical power to nd signicant
effects in these groups.
For women the unemployment rate is signicant for
cancer and other diseases with a sign suggesting a
procyclical relationship. However, these relationships
are no longer signicant if the analyses are restricted to
the 19811991 period.
Time lags
It is possible that there is a time lag between changes
in economic activity and the mortality risk. We tested
for this by including four lagged variables for each
business cycle indicator, i.e. the business cycle indicator
in years: t  1; t  2; t  3; and t  4 (the results for the
lagged variables are not shown in Tables 3 and 4). We
carry out these tests both for the total mortality and for
the cause specic mortality. We nd little evidence of
any signicant and consistent lagged effects of the
business cycle indicators on mortality. For total
mortality only two of the lagged variables are signicant
(t  1 for unemployment with a negative sign and t  1
for the deviation from the trend in GDP with a positive
sign), but the signicant results disappear if the analysis

ARTICLE IN PRESS
U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

is restricted to the 19811991 period. For women none

of the lagged business cycle indicators are signicant.
For cancer the same two lagged variables as for total
mortality are signicant for men, but again the result is
not stable towards varying the time period. The only
other signicant results for cause specic mortality are
for other external deaths for men, where ve of the
lagged variables are signicant (t  3 (positive sign) and
t  4 (negative sign) for the unemployment rate; t  1
(positive sign), t  2 (negative sign), and t  3 (positive
sign) for the notication rate). These signicant results
also disappear if the analysis is restricted to the 1981
1991 period.

Discussion and conclusions

We have analysed the effect of business cycles on
mortality using a large individual level data set. For men
we found a signicant countercyclical relationship
between business cycles and the mortality risk for
four of six business cycle indicators and a nonsignicant effect for the other two indicators. For
women we could not reject the null hypothesis of no
effect for any of the business cycle indicators. These
ndings were relatively stable towards a number of
sensitivity analyses.
Our results show that the relationship may be
sensitive towards the business cycle indicator used. To
use the unemployment variable was problematic in our
study, because it was difcult to separate the cyclical
variations in unemployment from changes in the level of
unemployment. Four of our six business cycle indicators
had a signicant effect for men (the notication rate, the
capacity utilization, the condence indicator, and the
GDP change). What is characteristic of the signicant
indicators is that they mainly focus on changes from the
current level, rather than deviations from the long run
trend. The change in GDP by denition focus on
the change in economic conditions compared to the
previous year. The condence indicator is based on
the number of rms reporting negative/positive changes,
and can also be interpreted as a measure of the change in
economic activities compared to the current level. For
the capacity utilization variable it is less clear to what
extent it measures the change from the current level or
the deviation from the long run trend, but given that
rms adjust their capacity in response to economic
upturns and downturns it seem natural to also interpret
this variable as mainly capturing the change in economic
conditions. This is also supported by the high correlation between this indicator and the GDP change and the
condence indicator. Also for the notication rate it is
not obvious to what extent it measures the change in
economic activities, rather than the deviation from the
long run trend. It measures the fraction of individuals

215

that are likely to enter unemployment in the next period,

and in that respect measure the change in unemployment. But the total change in unemployment also
depends on how many individuals that exit unemployment. In terms of correlations the notication rate is
most strongly correlated with the GDP change and the
condence indicator. The unemployment indicator and
the deviation from the GDP trend measure the deviation
of current economic conditions from the average
level.
Our results suggest that what is most important for
the mortality risk is the size of the change in economic
conditions compared to the current level. To test this
hypothesis further we reestimated our results using the
annual change in the unemployment rate. In these
estimations the coefcient for the change in unemployment was 0.0235 (t-value=3.23) for men and 0.0017 (tvalue=0.21) for women. The results for the change in
unemployment are thus consistent with the results of the
other business cycle indicators.
An interesting nding was that the results differed
between men and women.12 For women we found no
signicant effect for any of the business cycle indicators.
Our results therefore suggest that recessions adversely
affect the mortality for men, but not for women. Why
the health of men is more sensitive towards the business
cycle is unclear, but it is possible that men are more
sensitive towards changes on the labour market if they
are the primary breadwinner of the household. For
instance, in the identity model of Akerlof and Kranton
(2000), men loses identity if they earn less than their
wives or perform housework. To test this hypothesis
further we ran separate regressions for single women
(women that are not married/cohabiting), to test if they
are more likely to respond in the same way as men.
Although the coefcients for the six business cycle
indicators were consistent with a countercyclical relationship between the business cycle and the mortality
risk in these estimations, the effect was not signicant
(the p-values varied between 0.225 (GDP change) and
0.923 (unemployment rate)).
The stronger effect of the business cycle on men is
consistent with the recent study of Dee (2001) that
studied the effect of the business cycle on binge drinking.
Dee (2001) found a countercyclical effect between
business cycles and binge drinking, and that the
12

We also tested this by including both men and women in

the same regression and including an interaction term between
male gender and the business cycle. This interaction was: 0.0008
(t-value=0.20) for the unemployment rate, 0.0195 (t-value=2.08) for the notication rate, 0.0112 (t-value=2.69)
for the capacity utilization, 0.0018 (t-value=2.55) for the
condence indicator, 0.3844 (t-value=1.14) for the deviation from the trend in GDP, and 0.0125 (t-value=2.34) for
the GDP change.

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U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

recession induced increase in binge drinking was

substantially larger for men than for women.
The countercyclical pattern between the business cycle
and mortality for four of our indicators was signicant
both for working-age men and older men (although
if the time period was restricted to 19811991 the
effect was not signicant for older men). In relative
terms the effect on the mortality risk was substantially
stronger for working-age men (the relative risk
change due to a change in the business cycle indicator
was more than twice as high for working-age men).
The stronger relative effect for working-age men is
natural given that they are more directly affected by
changes on the labour market. It may indeed be
difcult to understand why a signicant effect was also
observed for older men that are not working. One
possibility is that economic conditions are a general risk
factor for all men independent of if they are in the
labour force or not. The transitory income of older
individuals may also vary with the business cycle (e.g.
transfer payments and the income from capital may vary
with the business cycle), as may the provision of public
goods and the provision of publicly provided private
goods.
We also analysed our results for different causes of
death. For men we found a signicant countercyclical
pattern between the business cycle indicators and
cardiocascular mortality, cancer mortality and suicides.
For other diseases and other external causes no
signicant effects were found. In relative terms the
countercyclical effect for men was strongest for suicides.
The result for suicides for men is consistent with
recessions causing mental health problems, and the
literature about unemployment as a risk factor for
suicide (Jin et al., 1995; Dooley et al., 1996; Mathers &
Schoeld, 1998). It is also consistent with the economic
theory of suicide developed by Hamermesh and Soss
(1974), which predict a countercyclical relationship
between business cycles and suicides.
Stress is a risk factor for cardiovascular diseases and
the hazardous effect of recessions on the risk of
cardiovascular mortality for men is consistent with
recessions leading to psychosocial stress (Elisaf, 2001;
Black & Garbutt, 2002; Krantz & McCeney, 2002).
There is also some evidence that stress may be a risk
factor for cancer (Colby & Lindsky, 1994; Jahn &
Becker, 1995), although it may seem unlikely that there
would be an immediate effect of the business cycle on
the risk of cancer. It is possible, however, that the
business cycle affects the survival probability of
individuals that have already developed cancer.
The results for cancer were less stable than the results
for cardiovascular diseases. If the time period was
restricted to 19811991 the signicant results for
cancer disappeared and the absolute size of the business
cycle coefcients dropped considerably. Our results for

cancer therefore have to be interpreted with great

caution.
In our baseline analysis we assumed that the business
cycle have an immediate effect on the mortality risk, i.e.
that there is no lag between the change in economic
conditions and the mortality risk. To estimate the effects
of any potentially lagged effects is inherently difcult
and somewhat arbitrary. In a sensitivity analysis we
tried including lagged business cycle indicators, but
found no strong evidence of such effects on mortality.
For several important risk factors that may be related to
economic conditions, such as high blood pressure and
high cholesterol levels, data from clinical trials also
support the notion that mortality is affected more or less
contemporaneously as the risk factor changes (Collins
et al., 1990; Shepherd et al., 1995).
It is interesting to compare our results to the
aggregated data results of Ruhm (2000). He found a
procyclical relationship between business cycles (proxied
by the unemployment rate) and mortality, which is
contrary to our result for men. Also, the results for
different causes of death differ between the studies. The
exception to this is suicides, which was the only cause of
death where Ruhm (2000) found a countercyclical effect.
In comparing the results between the studies it should be
emphasized that there are several important differences,
which limit the comparability. We used individual level
data, whereas Ruhm used aggregated data. The business
cycle indicators also differ between the studies, with the
exception of the unemployment rate that was used in
both studies. As our study shows the result may be
sensitive towards the business cycle indicator used. The
studies are also for two different countries (Sweden and
the US) and two different time periods.
In a more recent study Ruhm (2003) also present
results for the US based on individual level data, which
increase the comparability to the present study
(although the remaining comparability problems noted
above, still apply). Ruhm (2003) estimates the relationship between the state unemployment rate and various
morbidity indicators on the individual level. He nds
that most measures of health improve as the unemployment rate increase. This result is also contrary to our
ndings for men. Given these differences in results,
further work is clearly needed to disentangle the
importance of the differences between the studies, and
to draw strong conclusions about the effect of business
cycles on mortality.

Acknowledgements
We thank Anders Bjorklund, Glenn C. Blomquist,
Ann-Christin Jans, Christopher J. Ruhm, Eskil Wadensjo and two anonymous referees for helpful comments and suggestions. Financial support from the

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U.-G. Gerdtham, M. Johannesson / Social Science & Medicine 60 (2005) 205218

Swedish National Institute of Public Health and the

Swedish Council for Working Life and Social Research
(Contract 2002-0376) to Gerdtham and the Swedish
Research Council to Johannesson is gratefully acknowledged.

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