Suicide is an uncomfortable and emotive topic, but an important one for occupational health to understand. Dr Simon Walker and Professor Anne Harris consider suicide in society, its impact on work, and why medical professionals face heightened risk.
“…is it something difficult? Life is a cycle; trees fall. Tread, then, on disorder, set down my misery. Let Thoth judge me, and the gods become content: let Khonsu intervene for me, he who writes truly” – Translation of The Berlin Papyrus No. 3024, generally known as ‘The Debate between a Man and His Soul’.
The above quote comes from a 4,000-year-old document written, scholars believe, by a man debating his desire to end his own life (Allen, 2010). The narrative continues as he considers his place within the world and the West (the afterlife) and the elements of his existence he seems to have lost including a romantic relationship, family, self-purpose, and his work.
These multifactorial pressures on his decision remain relevant today in cases of suicide and suicidal ideation as they were over 4,000 years ago. Yet, consideration of suicide in almost all avenues of society outside of sensationalism and fiction is limited.
Suicide is an uncomfortable and emotive topic. As an act, the deliberate rejection of life has remained controversial in most cultures, religions and societal settings for thousands of years. As always there are exceptions, depending on the time, place, and person involved, yet for the most part, suicide remains a byzantine political, moral, and social issue.
Suicide accounted for nearly 800,000 deaths globally in 2021 (WHO, 2021). It has been theorised that, for each suicide completion, there are up to 25 suicide attempts (Berardelli et al, 2020). Moreover, individuals who attempt suicide have an increased statistical likelihood of completing suicide during another attempt within 12 months of the first incident (Isometsä & Lönnqvist, 1998).
This article will explore how suicide represents a significant factor in the loss of life globally and consider suicide within the framework of society, research and occupational health, with a focus on nursing as a case study.
Suicide in society
One of the primary issues associated with suicide is stigma and related cultural and societal reactions. Most modern cultures consider the act of self-destruction in unfavourable ways, ranging from extremist forms of posthumous punishment such as expulsion from religious groups or burial under crossroads, sometimes with a stake through their body, through to societal stigma and shame cast on family members and monetary penalties, such as the retraction of financial aid and pensions. This barbaric practice was condemned in Parliament in 1822 after the foreign secretary, Viscount Castlereagh, died by suicide but was buried in Westminster Abbey. An Act passed in 1823 allowed suicides private burial in a churchyard, but only at night and without Christian service. A review of the law resulted in a new Act in 1882 allowing burial in daylight hours. Parliament did not decriminalise suicide until 1961.
Within modern western society, suicide is typically treated with more sympathy than in history. Suicide cases in the 21st century are typically presented in Western culture as tragic losses, with a significant focus on the medicalisation of the act to consideration of mental health issues (WHO, 2021). Individuals who consider or complete suicide are more often classified as experiencing significant mental health trauma and in desperate need of help.
The opening page for resources on suicide for Psychology Today states: “Every suicide is a tragedy and to some degree a mystery. Suicide often stems from a deep feeling of hopelessness. The inability to see solutions to problems or to cope with challenging life circumstances may lead people to see taking their own lives as the only solution to what is really a temporary situation… Depression is a key risk factor for suicide…”
Impact on work
Yet, despite a wealth of examples showing a positive focus on the prevention of suicide and help in response to suicidal ideation, stigmatisation of suicide remains prevalent.
More CPD for occupational health
One of the primary issues associated with suicide prevention is the fear of exhibiting suicide intentions and the associated ramifications. Individuals considering suicide may be concerned that the admittance of their feelings may impact their relationships, friendships, occupation, opportunities, and reflected perceptions of self. Within a work capacity, people experiencing mental health issues and/or suicidal feelings may fear losing their job or be concerned about being regarded as incapable or unstable (CIPD, 2021).
Societally, there remains a continuing issue concerning masculinity norms and the stigma attached to requesting mental health support (Milner et al, 2018). Men are significantly less likely to seek out mental health help than women, which has led to researchers like Chatmon (2020) making claims such as “American men are subjected to a culture where the standards of masculinity are literally killing them”.
Impact on others
The impact of suicide is not limited to the individual who contemplates or completes the act. Many individuals subsequently experience mental health trauma as a result of a suicide attempt or knowing someone who has died by suicide. Both of these groups are statistically more likely to undertake suicide in the future.
Misunderstanding, ignorance, and fear are often at the root of stigmatisation and can play a significant role in the ostracism of individuals affected by suicide (Williams et al, 2018). Yet, online platforms and an increasingly socially aware younger generation appear to be more understanding. This was outlined by Nathan and Nathan in 2020 after they published their findings that social media (Facebook and Reddit) were typically empathetic toward American suicide cases. They concluded that “suicide is not stigmatised, most believed it is preventable and it is a person’s right to die by suicide” (Nathan & Nathan, 2020). However, this sample contained a minimal demographic of predominantly white and young participants, with many likely to have been associated with suicide and therefore perpetuating bias as is often found on social media (Cinelli et al, 2021).
Misunderstanding, ignorance, and fear are often at the root of stigmatisation and can play a significant role in the ostracism of individuals affected by suicide.”
The presentation of suicide in the public eye has also been questioned about replication through sensationalism and celebrity deaths. Writing in the BMJ in 2020, Gunnell and Biddle warned about the ramifications of detail, sensationalism, and detailed accounts of suicide deaths within the media. They noted that reporting of suicides by Robin Williams and Caroline Flack saw dramatic increases in online searches into suicide methods as well as potentially correlated rises in suicide rates as high as a 10% increase over the five months after Williams’ death (Gunnell & Biddle, 2020). The researchers maintain that sensationalism reporting and poor use of terminology within the media may have a significant triggering impact.
Suicidology, the study of suicide, is a relatively small field of academic and scientific research. Those that are involved tend to fall into three distinct camps of research: epidemiological, biological, and interventionist (Hjelmeland and Knizek, 2010). This is not an issue, and there is often some crossover, however, this leads to the predominant focus on quantitative research (Galasinki, 2017).
Purists in many research fields prefer the study of numbers and statistics to qualitative research, which almost always stubbornly refuses to remain within the chosen variables. Suicide statistics, including those presented in this article, tend to provide clear-cut data, which is more often than not both alarming and soothing in equal measure. Take the 2020 NRS Scotland data which illustrated that Dundee had the highest suicide rates between 2016 to 2020 with 23.9 deaths per 100,000 people (NRS, 2021, p.5). This is alarmingly high when presented against East Renfrewshire’s 8.7 deaths per 100,000 (NRS, 2021). However, as a percentage, the rate for Dundee is only 0.02% of the local population.
Qualitative data is also problematic, subject to interpretation and bias, and much harder to validate. Yet, qualitative data can also offer a clearer understanding of the individual who is much more than a number hidden within a statistic.
In 2012 nurse Jacintha Saldanha completed suicide after inadvertently revealing confidential information to two Australian radio hosts about Kate Middleton’s recovery at the King Edward VII hospital. In one of the three suicide notes left by Saldanha, she wrote: “Please accept my apologies. I am truly sorry. Thank you for all your support. I hold the Radio Australians Mel Greig and Michael Christian responsible for this act. Please make them pay my mortgage. I am sorry.”
Saldanha’s death is much more than a statistic. Such sources allow for a histological understanding of the individual, their environment, and their circumstances. Each suicide is theorised to impact upwards of at least 60 individuals (Pitman et al, 2014) totalling between 48-500 million people who might be exposed to suicide bereavement each year based on the current global annual suicide statistics of near 800,000 deaths (Levi-Belz & Gilo, 2020). Each individual associated with a completed or attempted suicide is statistically at risk of increased mental health trauma and suicidal consideration. Qualitative research helps us to attempt to understand not simply the numbers of suicide, but the individuals at the centre of it.
Each suicide is theorised to impact upwards of at least 60 individuals.”
It is for this reason that future attempts to understand suicide must mix quantitative and qualitative investigation methods. Similar to many factors considered within occupational health, suicidal action and ideation should not be considered within the blinkered sphere of the medical gaze. It is essential to employ an understanding of the biopsychosocial model (Engels, 1977) to recognise and support cases of suicidal ideation, suicidal action, and survivor related impacts of suicide. Only through the deconstruction of compartmentalism will recognition, support, and prevention of suicide as an individual, medical, and societal issue improve.
Occupational health’s role
Rarely, if ever, is a suicide singularly motivated. The pressures that can lead an individual to suicide are typically multifactorial and empirical understandings of suicide regard suicidality as the product of the interaction of several risk factors including distal, long-course factors, and proximal precipitating factors (Moselli et al, 2021).
In regard to occupational health, the question has been raised as to the extent that an employer must recognise and support individuals with suicidal associations. The 2020 CIPD advice booklet Responding to Suicide Risk in the Workplace states: “Employers are in a unique position for their employees, and with that comes responsibility. Aside from a legal duty of care to provide a safe working environment for employees, there is a strong moral and ethical responsibility on employers to support their health and wellbeing. This includes fostering an environment where mental health is treated with the same importance as people’s physical health, and the culture is one where people feel able to talk about suicidal feelings and seek help” (CIPD, 2020).
On an average workday, over a third is typically spent within a working capacity (ONS, 2022). The workplace is not a vacuum where workers can leave their thoughts, concerns, problems, and other aspects of their life at the door. Enhanced connectivity plays a significant role in the blurring of work and personal life in both directions, with workers being more connected to both sides of their lives at all times (Gaskel, 2020). As such, OH remains one of the most crucial sites of focus for the maintenance and improvement of individual health, including surveillance and support for suicide.
Suicide in healthcare
Nurses represent a working group that has a significantly higher likelihood of suicide than many other occupations globally. Work stress, work-life imbalance, personal and economic issues, and associated occupational pressures have all been highlighted as factors in nursing mental health decline and suicide. According to the NHS, medical professionals are currently at an elevated risk for suicide. Statistical research displayed on the front page of the NHS work support website outlines that medical doctors are twice as likely to complete suicide as compared to other occupations. Nurses are statistically four times more likely to complete suicide as compared to any other profession in the UK. Furthermore, female nurses are more at risk of suicide than their male counterparts. In 2019 it was reported that over 300 nurses had completed suicide within seven years.
Work stress, work-life imbalance, personal and economic issues, and associated occupational pressures have all been highlighted as factors in nursing mental health decline and suicide.”
Subsequent research into nursing suicide in England by the National Confidential Inquiry into Suicide and Safety in Mental Health (2020), facilitated by ONS findings, indicated a demonstrably high rate of suicide in nurses. The study concluded that this indicated a suicide risk 23% higher than in women in other occupations.
This is not an issue unique to the UK. Research in the United States (Kesley et al, 2017) found that nurses with suicidal ideation were less likely to report that they would seek such help (72.6%) than nurses without suicidal ideation (85%). In 2020 a study in San Diego (Davidson) corroborated these findings and concluded that: “Female nurses have been at greater risk since 2005 and males since 2011. Unexpectedly, the data does not reflect a rise in suicide, but rather that nurse suicide has been unaddressed for years.”
According to the Nursing Mental Health National Confidential Inquiry more than half of the nurses who died were not in contact with mental health services. This is one of the primary concerns raised by the Laura Hyde Foundation (LHF), whose founder Liam Barnes claimed in 2020 that their research demonstrated that stigma around suicide often meant that emergency workers are typically untruthful about sick leave reasons. Instead, individuals often will cite conditions such as musculoskeletal issues rather than admit to suicidal thoughts. Mr Barnes, whose nursing cousin’s suicide was the inspiration for the formation of the LHF, said: “There’s a fear of being struck off or letting colleagues down” (Allen, 2021). Therefore researchers, charities, and experts argue that it is crucial to improve access to mental health care in nurses, as in many groups, and remove perceived and actual stigma associated with the admittance of mental health issues within the profession.
Already similar concerns have previously been raised for doctors, who now have a dedicated mental health service, yet the support services for nurses remain insufficient.
A priority for employers
Suicide remains a global issue that has historically served as a partial indicator of societal malaise and a prompt for improvement. Within the field of occupational health, questions are frequently asked about responsibility and opportunity for suicide prevention, yet work plays a significant role in billions of individuals’ daily lives. The workplace remains a priority site for direct engagement and support for suicide prevention and postvention. OH can provide the toolkit and framework to enable individuals to access support services, tackle stigma and fear surrounding mental health and suicide, and enhance understanding of suicide action and ideation.
Returning to the letter written 4,000 years before this article, it is not the responsibility of Khonsu, the Egyptian God of Light within Darkness, to intervene today with suicide, but those with the most opportunity to help and recognise the cross-factorial risk elements of potential suicide. This is a role which must include but is not limited to, occupational health.
Ali, Z., & El-Mallakh, R. S. (2021). Suicidal Depression in Ancient Egypt. Archives of Suicide Research, 0(0), 1–17. https://doi.org/10.1080/13811118.2021.1878079
Allen ,D.(2021).Why nurses avoid seeking help when they’re in crisis. Nursing Standard, 36(9), 8-10. doi:10.7748/ns.36.9.8.s6.
Allen, J. P. (2010). The Debate Between a Man and His Soul: A Masterpiece of Ancient Egyptian Literature. BRILL.
Anon, Burying. (n.d.). Retrieved 29 May 2022, from https://www.parliament.uk/about/living-heritage/transformingsociety/private-lives/death-dying/dying-and-death/burying/
Berardelli, I., Forte, A., Innamorati, M., Imbastaro, B., Montalbani, B., Sarubbi, S., De Luca, G. P., Mastrangelo, M., Anibaldi, G., Rogante, E., Lester, D., Erbuto, D., Serafini, G., Amore, M., & Pompili, M. (2020). Clinical Differences Between Single and Multiple Suicide Attempters, Suicide Ideators, and Non-suicidal Inpatients. Frontiers in Psychiatry, 11. https://www.frontiersin.org/article/10.3389/fpsyt.2020.605140
Chatmon, B. N. (2020). Males and Mental Health Stigma. American Journal of Men’s Health, 14(4), 1557988320949322. https://doi.org/10.1177/1557988320949322
Cinelli, M., De Francisci Morales, G., Galeazzi, A., Quattrociocchi, W., & Starnini, M. (2021). The echo chamber effect on social media. Proceedings of the National Academy of Sciences, 118(9), e2023301118. https://doi.org/10.1073/pnas.2023301118
Davidson, J. E., Proudfoot, J., Lee, K., Terterian, G., & Zisook, S. (2020). A Longitudinal Analysis of Nurse Suicide in the United States (2005-2016) With Recommendations for Action. Worldviews on Evidence-Based Nursing, 17(1), 6–15. https://doi.org/10.1111/wvn.12419
Jaafar, E. A. & Haya Abdul-Salam Jasim. Jeroen van de Weijer (Reviewing editor) (2022) A corpus-based stylistic analysis of online suicide notes retrieved from Reddit, Cogent Arts & Humanities, 9:1, DOI: 10.1080/23311983.2022.2047434
Gaskell, A. (n.d.). Is A Blurred Work-Life Balance The New Normal? Forbes. Retrieved 30 May 2022, from https://www.forbes.com/sites/adigaskell/2020/05/11/is-a-blurred-work-life-balance-the-new-normal/
Isometsä, E. T., & J. K Lönnqvist (1998). Suicide attempts preceding completed suicide. The British Journal of Psychiatry: The Journal of Mental Science, 173, 531–535. https://doi.org/10.1192/bjp.173.6.531
Jabour, B. (2013, June 5). Australian hoax call DJ wins Austereo’s ‘top jock’ award. The Guardian. https://www.theguardian.com/world/2013/jun/05/australia-hoax-dj-wins-award
Levi-Belz, Y., & Gilo, T. (2020). Emotional Distress Among Suicide Survivors: The Moderating Role of Self-Forgiveness. Frontiers in Psychiatry, 11. https://www.frontiersin.org/article/10.3389/fpsyt.2020.00341
Nathan, N. A., & Nathan, K. I. (2020). Suicide, Stigma, and Utilizing Social Media Platforms to Gauge Public Perceptions. Frontiers in Psychiatry, 10. https://www.frontiersin.org/article/10.3389/fpsyt.2019.00947
Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry, 1(1), 86–94. https://doi.org/10.1016/S2215-0366(14)70224-X
Suicide | Psychology Today United Kingdom. (n.d.). Retrieved 29 May 2022, from https://www.psychologytoday.com/gb/basics/suicide
The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Suicide by female nurses: A brief report. 2020. University of Manchester. (n.d.). chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://documents.manchester.ac.uk/display.aspx?DocID=49577
Williams, S. M., Frey, L. M., Stage, D. L., & Cerel, J. (2018). Exploring lived experience in gender and sexual minority suicide attempt survivors. The American Journal of Orthopsychiatry, 88(6), 691–700. https://doi.org/10.1037/ort0000334