Relationship between suicide and employment
Suicide is a major public health problem, especially, though not exclusively, in developed countries. It is an act whose origins are complex, as, like all human affairs, each person and their circumstances play a role. Unemployment is known to be a risk factor for suicide. However, when we focus on the employed population, it is known that certain professional groups have higher suicide rates than others .
In Spain, according to the most recent data from the National Institute of Statistics , 3,947 deaths by suicide were recorded in 2020. The professions with the highest suicide rates in our country are those related to the state security forces and healthcare professionals. In a comprehensive meta-analysis on the subject, carried out by Milner and colleagues (Milner et al., 2013), it was found that professions with lower professional training requirements had a higher risk of completed suicide than other professions (cleaning staff or construction workers, among others). Higher suicide rates were also found among farmers, military personnel, security forces, firefighters, and healthcare professionals. Regarding the latter, doctors, veterinarians, nurses, and dentists are known to have an increased risk, as are emergency medical technicians and ambulance workers.
There are higher suicide rates among farmers, military personnel, law enforcement officers, firefighters, and healthcare professionals.
Due to the feminization of professions dedicated to caring for others, the rates of completed suicides in women and men in these groups are equal, unlike in the general population, where suicides are more frequent in men and attempts without a lethal outcome are more common in women.
Why do some professions have a higher risk of suicide?
When analyzing the reasons for higher suicide rates in certain professions, it is necessary to adopt models inspired by the analysis of complex systems. In this sense, it is important to consider factors ranging from strictly biological ones (sex, age) to personal factors and those associated with each individual's circumstances. Regarding the work environment, aspects related to financial compensation, social standing, degree of autonomy, job security or stability, work organization, the characteristics of the institution, interpersonal and hierarchical dynamics, the culture of each work environment, excessive working hours, and the appropriate demands (both strictly physical and mental, although these two aspects cannot be separated).
The main reasons that have been linked to the increased risk of suicide in certain professional groups (such as law enforcement or healthcare professionals) are:
- Accessibility and knowledge of the use of potentially lethal means .
- Reluctance to ask for help when a mental disorder or a situation of personal breakdown appears.
- Certain situations that these types of professionals must face in the workplace.
- Frequent exposure to traumatic situations lowers the threshold for daring to take the suicidal step.
Guide to recommendations for suicide prevention
Regarding the increased risk observed in professionals with lower professional training requirements, it may be related to factors that are not strictly occupational but to greater socioeconomic precarity or difficulty in accessing appropriate care at both the mental health and social resource levels.
There are other aspects of daily life that, regardless of profession, have been associated with greater emotional exhaustion. Some of these could be categorized under the heading of "new workplace alienation." Specifically, those who suffer the most are those with little control over their own work, low social and economic standing, and high job demands. This situation, if sustained over time, can, in certain circumstances, lead to a personal breakdown that causes the individual to consider suicide as an option.
Those who suffer the most are those with low control over their own tasks, low social and economic standing, and high job demands.
On the other hand, in professionals with high self-demands, the risk of suicide can increase in situations such as the degradation of hierarchical or academic status, being involved in disciplinary or legal processes, or other circumstances that are experienced as a loss of professional worth (mistakes, lack of consideration from colleagues, etc.), especially in those occupations with a high vocational content in which work is a core aspect of personal identity and is threatened for one reason or another.
Trying to understand suicide: changing the paradigm
For years, John Mann's stress-diathesis model (Mann, 1999) has been used to explain suicide based on an imbalance between risk and protective factors. This model posits that an individual's vulnerability, conditioned by a combination of biological, psychological, and social variables, is impacted by certain stressful situations (depression, traumatic events, etc.) that could trigger suicide. The model emphasizes that an underlying mental disorder, the most frequent of which is depression, can be identified in 90% of suicides.
Lately, the approach to suicide has shifted from a clinical perspective, and while not disregarding the importance of Mann's model, the emphasis has been placed on the mental process that leads someone to decide to take their own life . This is because it is this process that can differentiate one individual from another, even those who share the same risk and protective factors. The models of Edwin Schneidman, Roy Baumeister, Thomas Joiner, and Maurizio Pompili (Pompili, 2018) fit within this framework. An even more ambitious, yet necessary, approach from an anthropological standpoint should enrich these contributions, which are more focused on the "intrapsychic," with more sociological perspectives. These seek to link suicide rates to changes in lifestyles, personal relationships, and the management of distress, among other factors associated with a specific context.
A Public Health Problem
On a mental level, most suicides occur in response to intolerable psychological pain, although some suicides may stem not so much from despair as from self-sacrifice for an ideal (as in the case of suicide bombers or terrorists who immolate themselves for a greater good, or those who commit suicide in the context of funeral rituals but also for reasons of honor). It is estimated that for every completed suicide, there are between 10 and 15 suicide attempts. The severity of these attempts can be assessed by considering their medical consequences. However, from a psychopathological perspective, it is crucial to evaluate whether the individual has taken steps to avoid rescue and the degree of lethality intended by the method used. It is also important to assess whether, after the suicide attempt, the person reflects on and criticizes what happened or expresses regret. Exploring these aspects is key to deciding on the most appropriate treatment to follow after such an attempt.
Lately, the approach to suicide has changed from a clinical point of view and the emphasis has been placed on the mental process that leads someone to decide to take their own life.
From a mental perspective, the person who considers and ultimately attempts suicide (which can be fatal) most often enters a process (lasting seconds, minutes, or, frequently, days) in which this option begins to be seen as the only way out of an unbearable internal suffering. This suffering can be triggered by a situation that, generally speaking, might be experienced as failure, loss (real or symbolic), or unmet expectations. The predominant emotion is not always sadness but can be anger and, less commonly, fear . This uncontrollable distress is usually accompanied by intense unease (which may manifest as agitation, insomnia, or despair). As this intense distress intensifies, consciousness enters a tunnel-like state, so to speak, in which death itself becomes the only alternative to suffering. Any reasons to continue living are disregarded.
This situation of intense psychological pain ultimately triggers a mode of thinking that is, in a sense, intolerant of other ways of coping. Suicide becomes the only way out for a troubled mind that sees only that option. The process can be halted at that point if the individual decides to seek help (they would then be emerging from the tunnel vision, with only one final option). But it can also continue and reach a point where they feel capable of carrying it out. This is what is called "acquired capacity" for self-harm or "disinhibition." Sometimes, substances like alcohol or others facilitate this, activating precisely the disinhibition necessary to take the final step toward the fatal end. There is also a greater capacity to do so among those who have made previous attempts or are "familiar" with death, as is the case with some of the occupations we mentioned earlier.
Throughout this process, a key clinical element is the quality of the therapeutic relationship . Equally important is the ability to calm the intense agitation that often accompanies psychological distress. Both aspects can help the individual overcome the certainty that suicide is the only solution to their suffering. For individuals who have access to lethal means, it is crucial that they do not have access to them during periods of intense psychological distress. Support from a supportive network is also essential, whenever possible, so that the person in crisis does not feel isolated in their pain. While they may not always be able to provide relief, they can, for example, encourage the individual to seek specialized help if necessary. In cases where the risk of suicide is imminent, hospital admission to a psychiatric unit may be necessary to minimize, as much as possible, the possibility of self-harm and help reduce the intense distress.
Prevention strategies in the highest risk professions
To prevent suicide in high-risk professions, three lines of intervention must be considered: universal prevention (preventing suicide from occurring in the first place), selective prevention (facilitating early detection, for example, of suicidal ideation), and indicated prevention (intervening after a suicide attempt has already taken place). To date, at the general population level, the two most effective prevention strategies in this regard have been public health measures that have helped restrict access to lethal means (such as architectural barriers or the use of domestic gas) and improvements in the identification and treatment of depressive states and other situations that trigger suicidal ideation, as well as the provision of specific intervention programs when suicide risk is identified.
Some programs, especially in English-speaking countries, have emphasized universal prevention measures for high-risk professional groups. Most interventions, which can be conducted in person, remotely, or through a combination of both, focus on improving strategies for identifying mental distress, thereby preventing its denial, minimization, or rationalization, as well as delays in seeking help when needed. They also aim to facilitate a shift in attitudes toward mental health disorders within these professions, avoiding internalized stigma and promoting a proactive approach to distress. Some studies support the effectiveness of these interventions in reducing suicide rates in these groups. Universal prevention is typically the responsibility of healthcare institutions or professional associations, or of broader suicide risk prevention programs promoted by the health authorities of each country.
The two most effective prevention strategies have been public health measures that have helped to restrict access to lethal means and improvements in the identification and handling of situations that trigger suicidal ideation.
Regarding selective and indicated prevention , it is crucial that individuals in these professional groups are aware of and have access to readily available resources where they can seek help when they feel their coping mechanisms have failed. And, once they seek help or access specialized treatment resources, it is key that the professionals attending to them (generally those with expertise in mental health) can identify those at higher risk. This assessment cannot be based merely on an algorithm that considers risk and protective factors, but rather on evaluating when the individual may be entering the mental process described earlier. In these circumstances, it is important to develop a joint plan to prevent the act of suicide. When a suicide attempt has already occurred and we address it as healthcare professionals, we are talking about indicated prevention, which usually takes place in emergency or hospital settings. A crucial aspect for professionals at higher risk of suicide is that, in any prevention plan, the individual internalizes the importance of asking for help and accepts self-imposed limitations (sometimes temporary) regarding access to potentially lethal means when in a more vulnerable situation. In this regard, it is extremely helpful, in these circumstances, to have the support of those around them to care for and protect the person, provided they accept it.
Luis San Molina
It is also crucial not to overlook the importance of what is known as "postvention," that is, psychological intervention (often in a group setting) with the colleagues of the person who died by suicide. This type of approach not only helps in processing the grief that this "different" kind of death triggers, but can also help prevent further attempts that might occur through imitation or contagion (what has been called the "Werther effect").
It is known that some professionals have an increased risk of suicide compared to others. Beyond individual characteristics that may account for this, common factors in these professions include easy access to and knowledge of potentially lethal means, a tendency to delay seeking help when experiencing a mental health crisis or a situation of personal breakdown, and familiarity with death. These factors must be taken into account when implementing specific prevention strategies to reduce the incidence of this phenomenon in these professional groups.
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