Occupational Suicide Exposure and Impact on Mental Health: Examining Differences Across Helping Professions

Abstract

The purpose of the current study was to examine the relationship of suicide exposure with depression, anxiety, and post-traumatic stress disorder across three occupational groups likely to be exposed to suicide (i.e., first responders, crisis workers, mental health professionals). An online survey was completed by 1,048 participants. Results indicated that first responders, mental health professionals, and crisis workers were all exposed to suicide in the routine course of their occupation. Exposure to suicide significantly impacted mental health, specifically on depression, anxiety, and PTSD symptoms. The level of exposure to suicide was associated with higher levels of depression, anxiety, and PTSD.

Keywords

depression anxiety post-traumatic stress disorder occupational suicide exposure

There are a number of professions in which workers routinely have exposure to suicide. These professions include first responders (e.g., law enforcement officers, firefighter, and emergency medical services), crisis workers, and mental health professionals. However, little is known about the prevalence or impact of exposure to suicide(s) experienced by members of these groups and if they differ.

Exposure to trauma has been linked to increased risk for suicidal ideation and death by suicide (Loo, 2003; Stuart, 2008; Violanti, 2004). The impact of suicide exposure is theorized to lie on a continuum, with effects extending beyond the decedent’s closest family members (Cerel, et al., 2014). This continuum identifies most people who knew the decedent as “exposed,” a smaller group as “affected,” and the smallest group as “bereaved.” Studies indicate that half of the adult population has lifetime exposure to suicide (Cerel, et al., 2013; Cerell, et al., 2016) with approximately 135 people exposed to each death by suicide (Cerel, et al., 2019). There is growing evidence that exposure to the suicide of non-family members is associated with poor mental health and suicidal behavior among those with perceptions of closeness to the decedent (Maple, et al., 2017). Type and frequency of exposure may also increase the risk for posttraumatic stress symptoms (PTSD; Beaton et al., 1998).

First responders (FR) are not only exposed to suicides in the field (Cerel, et al., 2018), but to the suicide deaths of fellow first responders who take their own lives (Chae & Boyle, 2013; Violanti et al., 2008). Crisis workers and mental health professionals also work in fields in which they are likely to be exposed to suicide. Patient suicide can cause a wide range of long-lasting consequences and change working practices of mental health and social professionals (Gulfi et al., 2015). In a study of 211 health professionals who were interviewed following suicide or sudden death, suicide deaths were much more likely to impact professional practice and personal lives than sudden deaths (Draper et al., 2014). This study also found that being female, having the suicide occur within a week of having seen the patient as well as having less than five years of experience was related to professional or personal impact.

First Responders

Suicides of first responders - law enforcement officers (LEO), firefighters, and emergency medical service (EMS) have been notoriously difficult to study. There persists a culture of shame and stigma associated with suicide, making these suicides difficult to count.

In a previous study (Cerel et al., 2018), suicide exposure was examined in 813 law enforcement officers (LEOs) and found that LEOs had experienced an average of 30 work related exposures to suicide over the course of their careers, and 2.17 in the last year. One in five (22%) reported a scene that they cannot shake or have nightmares about. Almost three fourths (73.4%) knew someone personally who had died by suicide. There was a significant association between high levels of occupational exposure to suicide and behavioral health consequences including PTSD, persistent thoughts of a suicide scene, and the inability to shake a scene. The inability to shake a scene and was associated with increased symptoms of depression, anxiety, PTSD, and suicidal ideation.

LEOs have higher rates of posttraumatic stress disorder (PTSD) than other professions, and that the presence of PTSD is directly correlated with death by suicide (Brough, 2004; Chopko et al., 2014). These results are supported by research conducted in Australia, which suggests that there is considerable personal toll on community suicide postvention workers (Maple et al., 2019).

Firefighters have also been shown to have a high degree of professional exposure to suicide which is correlated with their own suicidal behavior (Kimbrel et al., 2016). Suicide is considered a serious problem in the fire service industry by the National Fallen Firefighters Foundation (2014). This is perhaps not surprising as 25.1% of firefighters considered suicide during their career and 12.1% made a suicide plan (Dill & Lowe, 2012). Some report that firefighter suicide occurs in clusters (Armstrong, 2014; Finney et al., 2015).

Emergency Medical Technicians (EMTs) experience intense brief and chronic stress (Donnelly, 2012; Reichard et al., 2011), through recurrent exposure to occupational stress and trauma (Vigil et al., 2019). This may explain the results from a national survey, which reports that EMTs have a higher incidence of suicidal thoughts and attempts than the national average by tenfold. Both contemplation of suicide and suicide attempts are strongly correlated with death by suicide (Newland et al., 2015). New research indicates that EMTs have a significantly higher chance to die by suicide than non-EMTs (Vigil et al., 2019). Additionally, a meta-analysis indicated a significantly elevated PTSD prevalence among ambulance personnel (Petrie et al., 2018).

LEOs, EMS and firefighters experience similar risk factors - shift work, a culture of independence, and exposure to high levels of trauma and stress, all variables linked to increased risk for suicidal ideation and suicide death (Armstrong, 2014; Stuart, 2008; Violanti, 2004).

Mental Health Professionals

Mental health providers (MHPs) are at the forefront of assessing, identifying, and responding to suicide risk. MHPs work in a variety of practice settings, namely in-patient, out-patient, partial hospital, and residential. Credentials and professional roles of MHPs also vary widely with the most common serving as therapists, mental health nurse practitioners, clinical social workers, psychologists, and psychiatric technicians. Accordingly, the way in which MHPs serve clients will vary across a continuum of generalized to specialized care (Roush et al., 2018).

There is growing evidence that many mental health professionals experience at least one loss of a client to suicide over the course of their career (Finlayson & Simmonds, 2019). However, the reported exposure in the research varies a great deal, ranging from 22% to 82% (Alexander et al., 2000; Grad et al., 1997; Howard, 2000; Trimble et al., 2000). There is evidence that MHPs experience strong emotional responses in their work with suicidal clients (Barzilay et al., 2019; Yaseen et al., 2017). MHPs sometimes also experience blame after a client suicide which increases self-doubt and distress (Hendin et al., 2000).

While it is not well-studied, there is some evidence that losing a patient to suicide can change MPHs practices and might have long-lasting effects (Gulfi et al., 2015). Despite these efforts to understand the role of clinical assessment and countertransference in suicide risk and prevention, there is limited research that assesses personal and occupational exposure to suicide among a wide variety of MHPs.

Crisis Workers

It is well established that crisis hotlines are widely used in suicide prevention but that crisis workers and centers vary widely (Mishara et al., 2007). Crisis workers includes those who respond in person, and over the phone or text to individuals experiencing acute crisis. Some crisis workers are strictly volunteers, while many are trained professionals. The type of crisis line can vary from a general focus (e.g., mental health hotline) to suicide-specific. There is ample evidence that telephone crisis workers experience vicarious traumatization due to their work, as well as stress and burnout, which might impact their work performance (Kitchingman et al., 2018). One previous study found that a high proportion of telephone intervention volunteers at a suicide prevention center had a history of suicide ideation and attempt (Mishara & Giroux, 1993). Experiences following exposure to traumatic accounts of human suffering may vary by personal coping styles of the crisis worker, the nature of the crisis, length of calls, and repeat callers (Kinzel & Nanson, 2000). However, there is virtually no research which describes crisis workers across different modalities or examines personal and occupational exposure to suicide in these workers.

The purpose of the current study was to examine the relationship between suicide exposure and mental health outcomes across three occupational groups likely to be exposed to suicide. The following research questions and hypothesis are put forth:

RQ1: Are there differences in suicide exposure between first responders, mental health professionals, and crisis workers?

RQ2: Do mental health outcomes (i.e., depression, anxiety, and PTSD) differ across the three professions of first responders, mental health professionals, and crisis workers?

H1: Suicide exposure is associated with levels of depression, anxiety, and PTSD.

Methods

The researchers used snowball sampling to collect the data. An anonymous, electronic survey approved by the university IRB was emailed to local police departments, local fire departments, and EMS services. These contacts were asked to forward the survey link through email to any first responder, medical resident, mental health clinician, or crisis worker they knew who might be exposed to suicide in their work. This process continued, where existing participants identified new possible participants within their networks and forwarded them the online survey. The survey branches so that participants only saw questions specific to their job.

Participants answered the following question, “Which of the following best describes you” and self-identified as either a first responder, mental health professional, or crisis worker. First responders included law enforcement officers, firefighters, and emergency medical services workers. Mental health providers included therapists, counselors, social workers, psychiatrists, psychologists, and nurses (medical doctors were a separate category and not addressed in this paper). The participants that selected crisis worker were mobile and text crisis hotline workers and face-to-face crisis assessors (e.g., in jails, hospitals, or other agency offices).

The sample included 1,048 participants. Of those 64.8% were first responders (n = 679), 25.4% were mental health professionals (n = 266), and 9.8% were crisis workers (n = 103). Of the participants 53.7% (n = 563) were female and 46.3% were male (n = 485); ages ranged from 18 to 81 (M = 40.28, SD = 11.39). The majority of the sample were Caucasian (n = 945, 90.2%), non-Hispanic (n = 1005, 95.9%), and married or in a domestic partnership (n = 634, 60.5%). Most participants reside in the United States (n = 873, 83.3%) with 10.2% from the United Kingdom (n = 107), and 2.6% from Canada (n = 27). All analyses were conducted using IBM SPSS Statistics 26.

Instrumentation

Exposure to Suicide

Participants reported personal exposure to suicide, the suicide of a colleague, and the number of occupational suicide exposures. These exposures were summed together to form an overall exposure score.

Depression

The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) was used to measure depression symptoms. There were nine questions with responses ranging from Not at all to Nearly every day, with scores higher than 10 suggesting major to severe depression and a score of 8–11 an appropriate cutoff for clinically significant depression (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3281183/). The PHQ-9 was designed as a self-report for primary care patients and is applicable to general populations. The Cronbach’s Alpha in this study suggests the measure was internally consistent, α = .89.

Anxiety

To measure anxiety the GAD-7 was used (Spitzer et al., 2006). It included seven questions to measure general anxiety, answer choices ranged from Not at all to Nearly every day, with scores over 10 indicated moderate to severe anxiety. This measure had internal consistency, α = .91.

Posttraumatic Stress Disorder (PTSD)

The Short Screening Scale for PTSD was used to determine PTSD about the suicide (Breslau et al., 1999). This 7-item measure derived from a longer interview used with a representative random-digit dial study of trauma has been shown to be useful in epidemiological studies. Of the seven items, five of the symptoms query about avoidance and numbing and two about hyperarousal. A score of 4 or greater on this scale defined positive cases of PTSD with a sensitivity of 80% and specificity of 97% (Breslau et al., 1999).

Results

A majority of the participants reported personally knowing someone who died by suicide (n = 733, 69.9%). A large number of participants have been exposed to one or more suicides through their work (n = 812, 77.5%). Many participants also reported they had lost a colleague to suicide (n = 436, 41.6%). A suicide exposure score was then calculated for each participant by adding personal exposure, a colleague completed suicide, and occupational suicide exposure. First responders reported an average of 47.31 exposures (SD = 110.49); crisis workers had an average of 2.13 (SD = 3.57); mental health professionals had a mean of 3.41 (SD = 7.76) (see Table 1).

Table 1.

Descriptive Statistics for Suicide Exposure and Profession.

	N	Mean	SD	Std. Error	95% Confidence Interval for Mean		Min	Max
	N	Mean	SD	Std. Error	Lower Bound	Upper Bound	Min	Max
First Responder	679	47.31	110.49	4.24	38/98	55.63	0	1002
Crisis Worker	103	2.13	3.57	0.35	1.43	2.82	0	21
Mental Health Professional	266	3.41	7.76	0.48	2.47	4.35	0	92
Total	1048	31.73	91.48	2.83	26.18	37.27	0	1002

To answer RQ1: Are there differences in suicide exposure between different occupational groups?. Personal suicide exposure was reported by 75.8% of first responders, 69.9% of crisis workers and 54.9% of mental health professionals. Occupational suicide exposure was reported by 92.8% of first responders, 31.1% of crisis workers and 56. 4% of mental health professionals. Colleague suicide loss was reported by 58.8% of first responders, 9.7% of crisis workers and 15% of mental health professionals (see Table 2).

Table 2.

Personal, Occupational, and Colleague Suicide Loss Across Occupations.

	First Responder	Crisis Worker	MHP
Personal Suicide Loss	515 (75.8%)	72 (69.9%)	146 (54.9%)
Occupational Suicide Exposure	630 (92.8%)	32 (31.1%)	150 (56.4%)
Colleague Suicide Loss	386 (58.8%)	10 (9.7%)	40 (15.0%)
Totals (n = 1,048)	679	103	266

Table 3.

Descriptive Statistics for Depression, Anxiety, and PTSD Among the Three Professions.

	First Responder	Crisis Worker	MHP	Total
Depression (PHQ-9)
Mean	8.35	6.84	5.60	7.50
SD	6.06	5.39	4.09	5.68
Std. Error	.23	.53	.25	.18
Anxiety (GAD-7)
Mean	6.88	6.04	4.89	6.29
SD	5.50	5.29	4.38	5.28
Std. Error	.21	.52	.27	.16
PTSD
Mean	3.71	2.96	2.71	3.42
SD	2.63	2.00	2.17	2.52
Std. Error	.10	.21	.15	.08

Table 4.

Parameter Estimates for Suicide Exposure and Depression.

Variable	DF	Parameter Estimate	Standard Error	t Value	Pr > \|t\|
Intercept	1	2.21729	0.04152	53.40	<.0001
Suicide Exposure	1	0.00124	0.00042900	2.89	0.0039

Table 5.

Parameter Estimates for Suicide Exposure and Anxiety.

Variable	DF	Parameter Estimate	Standard Error	t Value	Pr > \|t\|
Intercept	1	2.19977	0.04041	54.44	<.0001
Suicide Exposure	1	0.00096240	0.00041751	2.31	0.0214

Levene’s test for equal variance suggested that the scores were heavily skewed, and the data did not satisfy the equal variance assumption. Therefore, the data was transformed using the log-transformation method and the Welch adjusted F ratio was used to test if suicide exposure differed between the three groups. The results suggest there is a significant difference on suicide exposure among the three professions, Welch’s F(2, 341.82)=437.80, p < .001. At least two of the professions differed significantly on their average exposure to suicide.

Games-Howell follow-up tests were then conducted to examine pairwise comparisons between the three groups. There were mean differences in suicide exposure between first responders and crisis workers (p < .001), first responders and MHP (p < .001), but not between MHP and crisis workers (p = .11).

Again, Levene’s test for equal variance suggested that the scores were skewed, and the data did not satisfy the equal variance assumption. Therefore, the data was transformed using the log-transformation method and the Welch adjusted F ratio was used to test RQ2: Do mental health outcome (i.e., depression, anxiety, and PTSD) differ across the three professions of first responders, mental health professionals, and crisis workers? Overall, depression scores ranged from 1 to 27 (M = 7.50, SD = 5.68), anxiety scores ranged from 0 to 21 (M = 6.29, SD = 5.28), and PTSD scores ranged from 0 to 10 (M = 3.42, SD = 2.52). Descriptive statistics for depression, anxiety, and PTSD among the three professions are found in Table 3.

The Welch adjusted F ratio was used to examine differences between the three occupation types and their mental health scores. Results were significant for depression (PHQ-9), Welch’s F(2, 1045) = 19.01, p < .001; anxiety (GAD-7), Welch’s F(2, 1045)=12.10, p < .001; and PTSD, Welch’s F(2, 938), p < .001.

Games-Howell follow-up tests were then conducted to examine pairwise comparisons between the three professions. There was a mean difference on depression scores (PHQ-9) between MHP and first responders (p < .001). There were not significant mean differences on depression between first responders and crisis workers (p = .08), or between MHP and crisis workers (p = .16). The only significant mean difference for anxiety (GAD-7) was between first responders and MHPs (p < .001). There were no significant mean differences between first responders and crisis workers (p = .19), or MHPs and crisis workers (p = .45). Finally, there were significant PTSD mean differences between first responders and MHPs (p < .001), and first responders and crisis workers (p = .05). However, there was not a significant mean difference between MHPs and crisis workers (p = .33).

To address H1: Suicide exposure is associated with levels of depression, anxiety, and PTSD simple regressions were conducted to examine the relationships between suicide exposure and the mental health outcomes. First, the data were transformed into normality using the Box and Cox method (1964). The results for the transformed depression scale (PHQ-9) were significant, F(1, 1046) = 8.36, p = .004. This indicates that suicide exposure has a significant relationship with depression scores (see Table 4).

Next, a regression was used to test suicide exposure and anxiety (GAD-7) scores. Again, results were significant, F(1, 1046)=5.31, p = .02. Thus, suicide exposure also has a significant effect on anxiety scores (see Table 5).

Finally, a regression was used to test the relationship between suicide exposure and PTSD symptoms. The results were significant, (n = 941, due to missing data), F(1, 939) = 8.87, p = .003. Suicide exposure has a significant impact on reported PTSD (see Table 6). These results indicate that suicide exposure is associated with higher levels of reported depression, anxiety, and PTSD. Thus, H1 was supported.

Table 6.

Parameter Estimates for Suicide Exposure and PTSD.

Variable	DF	Parameter Estimate	Standard Error	t Value	Pr > \|t\|
Intercept	1	1.58970	0.02899	54.84	<.0001
Suicide Exposure	1	0.00086108	0.00028906	2.98	0.0030

Discussion

The results showed that most helping professionals had exposure to suicide. First responders (M = 47.31) reported substantially more exposure than mental health (M = 3.41) professionals and crisis workers (M = 2.13). However, this was mainly due to the discrepancy in occupational and colleague exposure as there were only small differences reported in personal exposure to suicide. In this study, 77.5% of all participants were exposed to occupational suicide. These results are consistent with previous research, healthcare professionals are likely to be exposed to suicide because of their occupations (Larkin & Beautrais, 2010). In part, because suicide rates in the United States continue to increase (Hedegaard et al., 2018). This is startling and highlights the great need for employers to provide mental health support, training, and resources to those in occupations likely to be exposed to suicide. Unfortunately, survey research consistently supports that across helping health professions there is an inadequate level of suicide risk assessment and prevention training at both the graduate school level and on-the-job training (Oranye et al., 2016). Some community mental health providers receive no formal suicide prevention training during their entire career (Silva et al., 2016). This study points to the need for a wide range of support for people in these occupations including professional training, informal support by colleagues, and formal intervention programs.

First responders reported higher symptoms of depression, anxiety and PTSD symptoms than mental health professionals and crisis workers. On average, these were all subclinical. The only significant difference between the occupations for depression and anxiety were found between first responders and mental health professionals. There were no significant differences between mental health professionals and crisis workers or first responders and crisis workers on either measure. Additionally, mental health professionals average depression and anxiety scores were both lower than first responders and crisis workers. This may be due to the training received or knowledge acquired on the importance self-care or might be due to the lack of daily trauma exposure of their job. Indeed, participants in a cohort-controlled study for therapists in training completed the Mindfulness-Based Stress Reduction program and reported significant decreases in stress, negative affect, rumination, as well as in state and trait anxiety (Shapiro et al., 2007).

First responders report experiencing significantly higher levels of PTSD symptoms than both mental health professionals and crisis workers. Perhaps these results are not surprising as first responders are exposed to significantly more suicides over the course of their career than MHPs or crisis workers. However, none of the occupations had a mean score over 4 which is the cut-off used to determine positive for PTSD (Breslau et al., 1999). In models predicting mental health outcomes, higher levels of suicide exposure contributed to depression, anxiety and PTSD symptoms. Future research should examine if length of time on the job substantially impacts mental health outcomes across occupations.

The results of this study begin to illuminate the relationship between suicide exposure and mental health outcomes among first responders, crisis workers, and mental health professionals; however, there were limitations. The wording in the survey differed slightly across professions for suicide exposure. First responders were asked to identify, “Approximately how many suicide scenes have you responded to in your first responder career?” Crisis workers were asked, “Approximately how many caller/crisis patients have completed suicide over your career?” and MHP were asked, “How many patients have completed suicide during your time as a Mental Health Professional?” It is conceivable then that first responders were reporting both suicide exposure and exposure to suicide attempts. Future researchers should examine if there is a difference between witnessing a suicide attempt and a suicide completion.

A nonrandom snowball sample was used to recruit participants and participants self-selected to complete the online survey, which may have caused sampling bias. The sample was more female than male with a large majority being Caucasian (90.2%) and non-Hispanic (95.9%). Finally, the results may better represent those that work in the United States than other countries as 83.3% of the sample identified that they reside in there. However, data from 2017 suggest suicide rates are comparable across the three countries: 1) United States with 12.84 per 100,000; 2) Canada with 10.91 per 100,000; 3) Britain with 10.1 per 100,000 (Ritchie et al., 2017; Office of National Statistics, 2017). For these reasons the generalizability of the results are limited. Future research should examine if differences exist cross-culturally between suicide exposure and health outcomes.

Conclusion

A majority of first responders, mental health professionals, and crisis workers were exposed to suicide in the routine course of their occupation. Exposure to suicide significantly impacted mental health, specifically depression, anxiety, and PTSD symptoms. The level of exposure to suicide was associated with higher levels of depression, anxiety, and PTSD. Although mental health professionals reported suicide exposure greater than crisis workers, this occupational group had the lowest levels of depression, anxiety, and PTSD scoring in the mild category for depression and anxiety and below the cut-off for PTSD. Crisis workers reported the lowest average exposure of the three groups but the group reported moderate levels of depression and anxiety. Occupational exposure to suicide is on the rise and this negatively impacts the mental health of those exposed. Therefore, it is vital that research based trainings, strategies, and support be developed and implemented with those working in occupations where possible exposure to suicide is high in order to combat the negative impact on the workers’ mental health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rosalie S. Aldrich

Author Biographies

Rosalie S. Aldrich is an Associate Professor in the Department of Communication Studies at Indiana University East. She is the John and Corinne Graf Professor of Communication Studies, a partially endowed honorary title. Her research focuses on suicide prevention, intention to intervene with someone who is suicidal, and suicide exposure. She currently serves as Chair of the Department of Communication Studies.

Julie Cerel is a licensed clinical psychologist and Professor in the College of Social Work at the University of Kentucky. She is the director of the Suicide Prevention & Exposure Lab at the University of Kentucky and currently serves as the Interim Associate Dean of Research. Her research has focused on suicide exposure/bereavement, suicide attempt survivors and suicide prevention. She currently serves as Past-President of the American Association of Suicidology.

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