Suicide among emergency and protective service workers: A retrospective mortality study in Australia,2001 to 2012

1 Introduction

Although active employment is a protective factor against suicide, emerging research suggests that employees in certain occupations are at an increased risk of suicide as compared to both the general population and the general working population [1]. There has been longstanding interest, for example, in suicide occurring among emergency and protective service occupations such as police [2], defence [3] and medical professionals [4, 5]. However, evidence about whether these occupational groups have elevated suicide rates compared to other occupations is mixed.

A 2003 meta-analysis of 101 samples on police suicide found the mean suicide rate of 19.3 suicides per 100,000 police personnel was lower than population rate of 25.2 per 100,000 [6]. Rates varied widely between the studies included in this meta-analysis, with higher rates associated with studies conducted over shorter time periods (i.e., <10 years), studies from Europe or North America, and those of regional rather than federal or metropolitan police forces.

Recent work suggests that although the suicide rate amongst active-duty military personnel has been historically lower than rates amongst comparable members of the general population [3], the suicide rate in this occupational group has doubled over the past decade, surpassing the civilian rate in some [7] but not all [8] countries. Thus, it appears that the timing and context of the study may contribute to variability in overall rates of suicide.

There has been comparatively limited attention paid to other emergency and protective professionals, such as ambulance personnel, fire-fighters, and prison and security officers. Studies on these occupations groups have mainly focused on cancer and other forms of mortality [9–11] or mental health outcomes [12, 13]. One of the few studies is a Norwegian cross-sectional study [14] which found that ambulance personnel report similar levels of suicidal thoughts, serious suicide ideation, and suicide attempts as other health professional occupations and the general population.

In Australia, there have been concerns over increasing rates of suicide in other emergency and protective services employees such as those above; particularly among ambulance personnel and fire-fighters [15]. However, at present, there have not been any published studies on suicide rates in these occupations. Further, there has been little investigation of suicide methods, despite suggestions that ready access to lethal means, such as firearms in protective services and defence employees [16, 17] and potent medicinal drugs in medical personnel [4, 18], may be associated with an increased risk of completed suicide in these occupational groups.

The aim of this paper is to address these knowledge gaps with an overview of suicide rates among emergency and protective service workers (including ambulance, fire-fighters, police and prison/security officers, and defence force personnel) in Australia over a 12-year period (2001 to 2012), and to compare these rates to all other occupational groups. We provide a description of the methods these employees used to end their lives because we aim to assess the degree to which access to lethal means may explain any observed elevated suicide rates in these occupational groups.

2 Method

3 Results

Table 1 displays the age and sex of suicide within emergency and protective service workers. Most suicides in these occupational groups occur among men, particularly for defence and prison security officers, and most occur in the middle (30–39 years) or younger (20–29 years) age groups.

The overall age-adjusted suicide rate in emergency and protective service workers over the period 2001 to 2012 was 22.4 (95% CI 19.5 to 25.2) per 100,000 in males and 7.8 in females (95% CI 4.6 to 11.0). The age-adjusted suicide rates among those in all other occupations was 15.5 per 100,000 (95% CI 15.2 to 15.9) for males and 3.4 (95% CI 3.2 to 3.6) among females.

Hanging was the most common suicide method across all occupations, apart from police, where firearms were the most commonly used method (n = 18, 36.73%) (Table 2). Inhalation of carbon monoxide and other gases was the next most common method. Compared to all other occupations, police (n = 18, 36.73%), prison and security officers (n = 18, 12.24%), and ambulance (n = 3, 10.34%) were more likely to use firearms to end their lives. Only a small proportion of defence force personnel used firearms (n = 1, 1.79%). A larger proportion of ambulance personnel used self-poisoning than other occupations (n = 5, 17.24%). Other methods which made up between six and 15% of methods used across the occupational groups comprised drowning, jumping in front of a moving object or from a height, cutting, electrocution, and fire and other explosives. A chi-square test revealed significant differences between occupational groups by suicide method (x²(20) = 77.27, p < 0.001).

Results of the negative binomial regression can be seen in Table 3. After controlling for age, sex, and year, ambulance personnel had an RR of 2.02 (95% CI 1.40, 2.93) compared to other occupations. Defence employees had particularly elevated suicide rates (RR 3.27, 95% 2.50, 4.28) compared to other occupations. It was apparent that prison officers (RR 1.81, 95% CI 1.54, 2.12) were at a heightened risk of suicide over this period, while police suicide rates were not significantly higher than other occupational groups (RR 0.70, 99% CI 0.53, 0.93). Fire-fighters had a non-significant elevated rate of suicide compared to other occupations (RR 1.20, 95% CI 0.81, 1.78).

Suicide rates in emergency service and protective service workers were significantly higher as a group than other occupations over a 12-year period (2001–2012) in Australia. Males in this group had rates 1.4 times as high as in other occupational groups, while females in emergency service and protective services had rates that were close to twice as high. Rates were highest amongst ambulance personnel and defence force employees. In contrast to previous work [6], suicide rates amongst police personnel were not significantly higher than other occupational groups in this study. Similar to suicide in the general population [23], hanging was the most common method, and the age-distribution of suicides occurred in younger and middle aged groups.

While there is no doubt a complex set of reasons for elevated suicide rates within these occupations, it is possible that the male dominated nature of emergency and protective service work plays some role. Population data indicates that there were over five times as many males employed in emergency and protective service occupations as females [21]. Further, the vast majority of suicides in these occupational groups were by males. The nature and characteristics of emergency and protective service work reinforces traditionally male gender norms and behaviours, comprised of characteristics such as stoicism (a man must not express his suffering), autonomy (a man must solve his problems alone, without the help of others), success (a man must succeed in all he undertakes), and aggressiveness (a man must be able to act aggressively, if need be) [24]. The influence of these gendered behaviours has long been seen to be risk factor for suicide, compounded by stigma and poor help seeking behaviour [24]. The smaller absolute proportion, but markedly higher, elevation of odds ratios for females might be explained by gender role conflict and their minority status comparative to men [25]. At the same time, we acknowledge the small number of females in the sample, which may raise the possibility of spurious findings.

Rates of post-traumatic stress [26, 27] and high alcohol use [28, 29] are reported to be higher in these occupations than the general population. These may be contributory factors, considering both PTSD and alcohol have been cited as risk factors for suicide [30].

Exposure to adverse psychosocial job stressors represent risk factors for mental health problems in several of these occupations and are a potential influence on suicide. For example, a cross-sectional study on police in Norway found perceptions of high job pressure and lack of support was associated with anxiety and depressive symptoms [31].

Research on ambulance personnel suggests these workers experience greater job stress than other occupations [11]. Further, adverse work related factors such as bullying and emotional exhaustion were independent predictors of suicide ideation [14]. Other studies have reported that adverse working conditions are associated with poorer mental and physical health in emergency services [12, 25]. These factors may contribute to the risk of suicide amongst these occupational groups.

While hanging was the most common method overall, police and prison/security officers frequently used firearms to end their lives, while ambulance personnel were more likely to use self-poisoning than other occupations. This may be connected to their greater ability to access lethal methods in the course of their work, and familiarity about how to use these methods. For example, ambulance personnel have relatively higher levels of exposure to drugs, but also have greater knowledge of how to treat self-poisoning (either intentionally or unintentionally) than other occupational groups. These factors may explain the high rates of suicide among ambulance personnel and aligns with past research on doctors [5], although we would acknowledge that in the present study there was a relatively low frequency of deaths by self-poisoning by ambulance personnel. In contrast to previous studies in the USA that have found that those in the army were more likely to use firearms to end their lives, [16] we did not find that those in the defence force were more likely to use firearms. We are unsure of why this may be the case, and would encourage further research on this finding. We would note that there has been limited research on prison and security officers [15, 16].

Our results highlight the need for prevention efforts among emergency and protective service occupations. We would suggest that suicide prevention efforts take an integrated approach to addressing suicide in these occupations, which would include addressing work-related stressors, access to lethal means, stigma about disclosing thoughts of suicide, as well as ensuring people at-risk are able to access help should they need it [32].

5 Limitations

Reliance on official suicide data from the NCIS represents a limitation of this study due to the possibility of under-reporting. This was particularly problematic in the initial years during which NCIS was established but may be an ongoing problem. Other possible problems include the miscoding of occupation by police collecting information on occupation or in the coding process, which may have occurred despite independent coding by two researchers and the use of a structured approach to the classification. Notwithstanding these issues, this study has a number of strengths, including the use of the best available quality population-level data on suicide, and coverage across an entire national population over a twelve-year period.

6 Conclusion

This study demonstrates that emergency and protective services are at elevated risk of suicide as compared to other occupational groups. Ambulance personnel, those employed in the defence force, and prison officers were particularly at risk. The vast majority of suicides occurred in males. There was a diverse range of suicide methods used in suicide cases. Suicide prevention efforts are needed for these at-risk groups.

Conflicts of interest

The authors report no conflict of interest.

Ethical standards

Ethical approval for this study was granted by the Justice Human Research Ethics Committee (Victoria) (CF/12/15778) and the Deakin University Human Research Ethics Committee (2015-161).