Suicide Prevention at the Workplace · Significance: Numbers of Suicides, Mentally Troubled...

Exploring the Impact of Suicide Prevention Research in the Workplace Moderator: Sally Spencer-Thomas

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Moderator

Dr. Sally Spencer-Thomas

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Speakers

Dr. Steven Stack

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Dr. Allison Milner

Suicide & Work Stress

Dr. Steven Stack,* Professor Department of Psychiatry and Department of Criminology

Wayne State University, Detroit, MI USA ICRC-S Webinar

Exploring Suicide Prevention Research: Evidence and Impact in the Workplace

March 24, 2015 Email: [email protected]

Research Gate Page: https://www.researchgate.net/profile/Steven_Stack

{webinar.STACK.031515Final}

mailto:[email protected]

https://www.researchgate.net/profile/Steven_Stack

Organization of Presentation

• 1. Dimensions of work stress; meta analyses of effect of work stress on physical and mental health; prevalence of work related suicide using NVDRS; interventions.

• 2. Qualitative research: Case studies from Detroit Suicide Project on 3 subtypes– job demotion, toxic coworkers, bullying.

• 3. Quantitative research: 6 case/control studies. • 4. Suicide by occupation and industry as clues to

distribution of deadly work stress. • 5. Suggestions for future research.

Dimensions of Work Stress

• Job Strain (involves tasks of a job) – Job Control (incl. skill level) – Job demands (e.g., workload, fast pace)

• Low Social Support: from coworkers, supervisors – Incl. individual bullying, discrimination, sexual harassment

• Organizational (In)Justice – Distributive Justice (or “Effort-Reward Imbalance (ERI)”are rewards fair?) – Procedural Justice (do rules apply equally to all) – Relational Justice (fair/cordial worker-supervisor relationships)

• Incl. organizational bullying, reprisals against whistle blowers • Loss/failure (e.g., unemployment, demotion, poor performance reviews) • Other: e.g., work related injuries, court proceedings • Karasek, R.A. 1979. Job demands, job decision latitude, & mental strain: implications for job redesign. Adm. Science

Q. 24, 285-307. Kivinmaki, et al. 2006. Work stress in the etiology of coronary heart disease. Scan. J. of Work & Environmental Health, 32, 431-442. Siegrist, J. 1996. Adverse health effects of high effort/low reward conditions . J. Occup. Health Psychol., 1:27-41.

Significance: Numbers of Suicides, Mentally Troubled Workers, & Interventions

• A significant number of suicides are located at work. • Between 1995-2001, 1,730 suicides took place at work. Accounted

for 31% of all deaths at work. • Between 2003-2010 1,804 suicides took place at the workplace, or

38% of all deaths at work. • 6.4% of workers suffer from major depression & 1.1% bipolar

disorder (National Comorbidity Survey) • Average age of an American suicide is 44, mid life working age. • While there have been many interventions to reduce workplace

stress, there is little or no data on their effectiveness (Germain, 2014: 151).

• Germain, G. 2014. Work-related suicide. An analysis of U.S. Government reports and recommendations for human resources. Employee Relations, 36(2):148-164.

SIGNIFICANCE: Work Stress (Effort/Reward Imbalance) and Heart Disease, Mental Illness

• Heart Disease. Meta analysis of 14 prospective studies determined that, on average, the adjusted risk ratio for a combination of high effort/low rewards at work was 1.58 (Kivimaki et al., 2006). (ERI strongest predictor)

• Mental Disorders (e.g., depression). Meta analysis of 11 studies high effort/low reward work stress increased relative risk for mental disorders by 1.84 (Stansfeld et al., 2006). (ERI strongest predictor)

• Sample ERI item: “Considering all my efforts & achievements, I receive the respect & prestige I deserve at work”

• Kivinmaki, et al., 2006. Work stress in the etiology of coronary heart disease. Scan. J . of Work & Environmental Health, 32, 431-442. Stansfeld, et al., 2006. Psychosocial work environment & mental health: A meta analytic review. Scan. J .of Work & Environmental Health, 32, 443-462.

Prevalence of Work Stress Related Suicides: NVDRS 11%

• An analysis of 30,000 suicides in the National Violent Death Reporting System (NVDRS) determined that at least 11% are related to “job problems” (Stack & Bowman, 2012)

• Job problems refer to issues at work which contributed to the suicide. These include: – tensions with a coworker, – poor performance reviews, – increased pressure, – fear of layoffs, & unemployment.

• 11% is likely an underestimate since the NVDRS is simply based on the data received from the county level. CDC coders can input only what they receive from local county medical examiners & coroners. In some cases work related strains can play a part in suicide, but if they are not mentioned/coded during local investigations, they go unrecorded. There is no standard protocol used nation wide for coding economic factors in cause of death certification at the local level.

• In Australia, a study determined that 17% (642/3775) suicides were work related (Routley, 2012) • Stack, S. & B. Bowman. 2012. Suicide Movies: Social Patterns, 1900-2009. Cambridge, Ma.: Hogrefe. Routley, et al.

(2012). Work related suicide in Victoria Australia, Int’l J. of Injury Control & Safety Promotion, 19, 131-134. CDC. 2009. National Violent Death Reporting System, Coding Manual, Volume 3. Atlanta: author.

Qualitative Work-- Detroit Suicide Project

• Job Demotion • Conflict with Coworkers • Worker (bully perpetrator) – supervisor conflict

Case Study: Job Demotion followed by Suicide Detroit Suicide Project

Detroit Suicide Project, ongoing analysis of 1,400 case files

Combination of Strains: Loss, Effort/Reward Imbalance, & Procedural Justice. • Ms. Smith, age 50, was called into her

boss’s office. To her surprise, she was notified that she was being demoted at her position with the company.

• Ms. Smith finished her work that day and left for home at 5 PM.

• She drove home and opened her garage with her remote control. She closed the door behind her and kept the engine running. She died of CO poisoning.

• Stack, S & Wasserman, I. 2007. Economic strain & suicide risk: A qualitative analysis. Suicide & Life Threatening Behavior, 37, 103-112.

Conflict between Co-workers & Suicide-- Case of the Steakhouse Slashers: Detroit Suicide Project

• Two workers in a steakhouse had a history of conflict. One night they attacked each other with knives. One required 120 stitches from wounds inflicted by his adversary. Subsequently, the employer fired both of them. Shortly thereafter the victor in the fight took his own life.

• Stack, S & Wasserman, I. 2007. Economic strain & suicide risk: A qualitative analysis. Suicide & Life Threatening Behavior, 37, 103-112.

Conflict Between a Bullying Perpetrator (Worker) and his Supervisor: Detroit Suicide Project

• A 35 year old white, single male had frequent altercations with his female supervisor at a large automotive factory. His coworkers had teased him and taunted him about it. Conflicts escalated until the man was “written up” by his female supervisor placed on temporary layoff. Shortly thereafter he suicided by firearm.

• Stack, S & Wasserman, I. 2007. Economic strain & suicide risk. A qualitative analysis. Suicide & Life Threatening Behavior, 37, 103-112.

Quantitative Work • Searched Medline, Soc Abstracts, for studies on

– death by suicide (suicide ideation, attempts omitted) – with a control group with which to compare the

suicides (descriptive studies on suicides only omitted) – with at least one measure of work stress

• 6 studies met the criteria • Findings mixed. Strongest findings are for one study of job

demotion & suicide. No studies on ERI .

Review of Case Control Studies on the Effect of Work Stress on Suicide Deaths

Author (year) Nation Number suicides/controls

Adjusted Work Stress Measures (* = p < .05)

Adjusted for Mental Disorders

Stack (2015) USA 1169/12728 Job Demotion* Yes

Law (2014) Hong Kong 63/112 Job strain (JS) overall JS mediated by mental disorders

Schneider(2011) Germany 163/390 Job Control (JC)* Job demands* Social support (SS)*

YES

Tsutsumi (2007) Japan 14/3111 Job control,* demands NO

Ostry (2007) Canada, saw mill workers

162/486 JC; Psych demand*; Phys demand; SS; noise.

NO

Feskanich (2002) USA, nurses 73/94033 work stress overall NO Stack & Scourfield, J., 2015, Recency of divorce, depression & suicide risk, J .of Family Issues, May, in press; Law, Y., Yip, P., Zhang, Y. & Caine, E. , 2014. The chronic impact of work on suicides & under-utilization of psychiatric & psychosocial services. J. of Affective Disorders, 168,254-261; Schneider, B. et al., 2011. Impact of employment status & work related factors on risk of completed suicide. Psychiatry Research, 190, 265-271; Tsutsumi . 2007. Low control at work and risk of suicide in Japanese men. Psychother Psychosom 76, 177-185; Ostry, A . et al., 2007. Impact of psycho-social work conditions on attempted & completed suicide among Western Canadian sawmill workers. Scan. J. of Public Health, 35, 265-271; Feskanich, D. et al., 2002. Stress & suicide in the nurses’ health study. J. of Epid. & Com. Health, 56, 95-98.

Job Demotion as a Work Stress Factor: Nat’l Mortality Followback Survey

• The second American NMFBS did measure two work stress constructs: unemployment and job demotion in the last year of life.

• Controlling for psychiatric morbidity (e.g., major depression), demographics, and protective factors (e.g., religiosity), job demotion was a leading predictor of death by suicide vs. natural causes.

• Those demoted at work in the last year of life were 7.29 times more apt to die of suicide than those who were not demoted.

• (Note a study of Hong Kong workers reported that 31% of suicides were in danger of demotion/job loss vs. only 8.3% controls (Law et al., 2014).

• Stack, S . & Scourfield, J., 2015, Recency of divorce, depression & suicide risk, J. of Family Issues, May, in press. Law, Y., Yip, P., Zhang, Y. & Caine, E. 2014. The chronic impact of work on suicides & under-utilization of psychiatric & psychosocial services. J of Affective Disorders, 168, 254-261

Effect of Job Demotion, Unemployment, and Controls on the odds of death by Suicide, ODDS RATIOS, Multivariate Logistic Regression, National Mortality Follow-

back Survey (N=13,897 deaths including 1,169 suicides) (Stack, S. & Scourfield, J., 2015, Recency of divorce, depression & suicide risk, J. of Family Issues, May, in press).

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Clues to Locating Areas of High Suicide & High Work

Stress • Suicide by Occupational

Groups • Suicide By Industry

Distribution of Work Stress: Occupations

• Suicide Rates Vary by Occupation. This variation may provide a window into which jobs are more or less stressful than average.

• Can suggest where suicide prevention resources are most needed.

Occupations with High/Low Suicide Risk

Data from the National Mortality Detail file found 15/32 occupations (32 with an adequate number of suicides to calculate reliable rates) had elevated or less than average suicide risk ratios. However, controlling out demographic covariates (age, gender, race, marital status), only 8/32 had significantly elevated or lower suicide risk. Elevated risk: doctors, nurses, dentists, artists, social workers, mathematicians/scientists. Lower Risk: Adjusted odds ratios indicated that clerks and farm workers had significantly lower suicide risk. (Stack, S. 2001. Occupation & suicide. Social Science Quarterly, 82 (June), 384-396.

Suicide Risk by Industry

• Suicide rates vary by industry. • This variation can also provide a window into

locating which industries have the highest suicide risk.

• An analysis of the Nat’l Longitudinal Mortality Study (1979-1989) determined that of 12 industries the ones most at risk of high suicide included: – Mining 4.39 RR Construction 2.59 RR – Reference category: Financial services/insurance

Suicide Risk by Industry

Kposowa, A. (1999). Suicide mortality in the United States: Differentials by industrial and occupational group. American Journal of Industrial Medicine, 36, 645-652.

DISCUSSION: Problem: Lack of Data on Job Stress & Suicide in the USA

• Large American datasets and databases with data on suicides and a control group (e.g., natural deaths, living controls) tend to have few, if any, measures of work stress – Nat’l Mortality Followback Surveys, – Multiple Cause of Death Files, – Mental Health Research Network database. – Suggest: Need a new Mortality Followback Survey or

Expansion of another large survey (e.g., National Health Interview Survey) to include items on work stress (especially ERI).

Other Suggestions for Future Research

1. Following leads in work stress and mental illness/physical illness, more attention needs to be drawn to ERI, effort-rewards imbalance (fair rewards) as a predictor of suicide.

2. Evidence on job control/demands as well as social support is rather mixed. Organizational stress & loss (e.g., demotion) may prove to be better predictors of suicide than job control/demands & social support on the job.

3. Controls for mental illness. Half of the existing work does not control for a possible covariate of suicide/work strain: mental illness. Future work needs to build a strong research model with adjustments for this factor.

4. Family stress + work stress interactions (Feskanich, 2002). Work stress may have its full impact on suicide in combination with other stress. Feskanich, D. et al. 2002. Stress & suicide in the nurses’ health study. J. of Epid . & Com. Health,56,95-98.

Improvements to the CDC NVDRS

1. Analysis of the narratives in the National Violent Death Reporting System is needed to clarity the degree to which each category of job problems is connected to suicide deaths. For example, of 30,000 cases there are over 3,000 suicides that were linked to job problems. Unfortunately, CDC coders do not code the subtypes of job problems.

2. Possibly CDC could instruct their coders to start to break down “job problems” into subcategories so we would have national estimates of just what kinds of work stress are most likely to foster suicide deaths.

3. It would help tremendously to include a control group of natural deaths with which the suicides (& homicides) could be compared.

THE END

McCaughey VicHealth Centre for Community Wellbeing

Workplace suicide prevention: Planning for tomorrow

Dr Allison Milner

Research Fellow, Work, Health and Wellbeing, University of Melbourne

Exploring Suicide Prevention Research: Evidence and Impact in Multiple Settings

ICRC-S Webinar March 24, 2015


§ Primary prevention § Work related risk factors § Occupations at risk § What we know about workplace

suicide prevention § Principles for the future

Overview

Primary Prevention (prevention, proactive) Aims to reduce potential risk factors and increase protective factors.

Secondary Prevention (Ameliorative, remedial) To equip people with the knowledge, skills and resources.

Tertiary Prevention (Reactive) To treat, compensate and rehabilitate

2007 LIFE FRAMEWORK PUBLIC HEALTH MODEL

Universal Intervention Selective Intervention Indicated Intervention Symptom identification Early treatment Standard treatment Longer term treatment and support Ongoing care and support


Primary prevention: The WHO guidelines (2006)

“Worker suicide is a complex interaction between individual vulnerabilities (such as mental health

problems), stressful working conditions, and living conditions (including social and environmental

stressors)…”

“The over-riding goal should be to create a working environment that is respectful to the individual, maintains worker integrity, and minimizes and

counteracts stress”



§ The majority of suicide cases occur among the employed population § The workplace is relatively untapped as a

location for suicide prevention!!

Suicide in the employed population

Suicide among the employed (and non employed) population during

the Global Financial Crisis


Age-adjusted suicide rates among the employed and economically inactive by sex, 2001 to 2010

Milner A, Morrell S, LaMontagne AD. Economically inactive, unemployed and employed suicides in Australia by age and sex over a ten-year period: what was the impact of the 2007 global economic recession? International Journal of Epidemiology. 43(5):1500-7.


Poisson regression reporting Incidence Rate ratios (IRRs) for suicide during years of the Global Financial Crisis (GFC) (2007, 2008, 2009)

compared to 2006, by sex.

Females Males

RR 95% CI p-value RR 95% CI p-value Economically inactive 2009 1.05 0.95, 1.16 0.345 0.98 0.93, 1.04 0.546

2008 1.19 1.08, 1.32 0.001 1.22 1.15, 1.29 <0.001

2007 1.12 1.01, 1.23 0.030 0.98 0.93, 1.04 0.61

2006 1 - - 1 - -

Employed 2009 0.87 0.79, 0.97 0.012 0.94 0.90, 0.99 0.013

2008 0.78 0.70, 0.87 <0.001 1.04 0.99, 1.09 0.124

2007 0.99 1.10, 0.84 0.843 1.07 1.02, 1.12 0.003

2006 1 - - 1 - -

Milner A, Morrell S, LaMontagne AD. Economically inactive, unemployed and employed suicides in Australia by age and sex over a ten-year period: what was the impact of the 2007 global economic recession? International Journal of Epidemiology. 43(5):1500-7.


Unemployment at the aggregate level

Job insecurity

Mental health problems/suicide?

Possible mechanisms

Milner, A., Kavanagh, A., Krnjacki, L., Bentley, R., & LaMontagne, A. D. (2014). Area-level unemployment and perceived job insecurity: Evidence from a longitudinal survey conducted in the Australian working-age population. Annals of Occupational Hygiene, 58(2): 171-181


Possible mechanisms

Milner, A., Kavanagh, A., Krnjacki, L., Bentley, R., & LaMontagne, A. D. (2014). Area-level unemployment and perceived job insecurity: Evidence from a longitudinal survey conducted in the Australian working-age population. Annals of Occupational Hygiene, 58(2): 171-181

Work related risk factors


Schneider, B., et al., (2011); Tsutsumi, A., et al., (2007); Takada et al. (2009); Ostry, A., et al., (2007); Feskanich, D., et al (2002)

Psychosocial job stressors and suicide

• Monotonous work • High job demands • Low job control

• Parallels findings in mental heath research….

Schneider, B., et al., (2011); Tsutsumi, A., et al., (2007); Takada et al. (2009); Ostry, A., et al., (2007); Feskanich, D., et al (2002)

Risks of suicide by occupational skill level


0. Military occupations 1. Managers, senior officials and legislators 2. Professionals 3. Technicians and associate professionals 4. Clerks 5. Service and sales workers 6. Skilled agricultural and fishery workers 7. Craft and related trades workers 8. Plant and machine operators, and assemblers 9. Elementary occupations

The ISCO Groupings

Milner A, Spittal MJ, Pirkis J, LaMontagne AD (2013). Suicide by Occupation: A systematic review and meta-analysis. British Journal of Psychiatry. 203(6): 409-16.


Results – 9 occupational groups

ISCO 1 – managers, ISCO 2 – professionals, ISCO 3 – technicians, ISCO 4 – clerks, ISCO 5 - services/sales, ISCO 6 - agricult/fishery, ISCO 7 - craft/ trades, ISCO 8 - machine operators, ISCO 9 - elementary



Suicide rates in the construction industry, with a focus on the GFC

Milner A, Niven H, LaMontagne AD. Suicide by occupational skill level in the Australian construction industry: Data from a national register of deaths over the period 2001 to 2010. Australian and New Zealand Journal of Public Health. 38(3): 281-285.

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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Suic

ide

rate

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Year Machinary and labourers Technicians and Trades Workers Suicide rate in all males


§ Unmeasured disadvantage § Lower education, access to services, social disadvantage

§ The quality of work

§ Exposure to other risks associated with work

§ Access to lethal means

§ Individual characteristics – selection effects

Why are some occupational groups at risk?


Modifiable risk factors

Bullying

Suicide Underlying vulnerability

Milner A, Page A, LaMontagne AD. Cause and effect in studies of unemployment, mental health, and suicide: a meta-analytic and conceptual review. Psychological Medicine. doi: 10.1017/S0033291713001621


Modifiable risk factors

Bullying

Suicide Underlying vulnerability

Milner A, Page A, LaMontagne AD. Cause and effect in studies of unemployment, mental health, and suicide: a meta-analytic and conceptual review. Psychological Medicine. doi: 10.1017/S0033291713001621


Workplace suicide

prevention – 2014 review

Milner A, Page KM, Spencer-Thomas S, LaMontagne AD (2014). Workplace suicide prevention: a systematic review of published and unpublished activities. Health Promotion International. First published online Sep 25 2014 pii: dau085.

Workplace suicide prevention - review

• Systematic review – MOOSE guidelines. Had to be provided to

employees of an organisation

• Results = 13 studies • Group 1 = stand-alone, short-term training

programs • Group 2 = suicide prevention initiatives for

‘high risk’ industries or occupations Milner A, Page KM, Spencer-Thomas S, LaMontagne AD (2014). Workplace suicide prevention: a systematic review of published and unpublished activities. Health Promotion International. First published online Sep 25 2014 pii: dau085.

Workplace suicide prevention - review

• Some evidence of a reduction in suicide attempts/deaths

• Some evidence of an increase in help-seeking behaviours

• No studies addressing adverse work-related exposures as risk factors for suicide

Milner A, Page KM, Spencer-Thomas S, LaMontagne AD (2014). Workplace suicide prevention: a systematic review of published and unpublished activities. Health Promotion International. First published online Sep 25 2014 pii: dau085.

Economic evaluation of

workplace suicide prevention

Doran C & Ling R (2014). The economic cost of suicide and suicide behaviour in the NSW construction industry and the impact of MATES in Construction suicide prevention strategy in reducing this cost. Brisbane, Queensland: Mates in Construction

Economic evaluation of workplace suicide prevention

• Implementation of MIC estimated to reduce suicide in NSW – 0.4 suicides per year, 1.01 attempts, 4.92 short

term absence

• Benefit of averting this harm is estimated at $3.66 million each year

Doran C & Ling R (2014). The economic cost of suicide and suicide behaviour in the NSW construction industry and the impact of MATES in Construction suicide prevention strategy in reducing this cost. Brisbane, Queensland: Mates in Construction

Take home messages

• Primary prevention • Tailor interventions • Do no harm • Plan evaluation from the outset


Thank you! allison,[email protected]

http://mccaugheycentre.unimelb.edu.au/


Acknowledgments

• The National Health and Medical Research Council Capacity Building Grant in Population Health (grant number 546248)

• The Victorian Health Promotion Foundation

References • Schneider, B., et al., Impact of employment status and work-related

factors on risk of completed suicide. A case-control psychological autopsy study. Psychiatry Res., 2011. 190(2-3): p. 265-70. Epub 2011 Sep 3.

• Tsutsumi, A., et al., Low control at work and the risk of suicide in Japanese men: A prospective cohort study. Psychother Psychosom, 2007. 76(3): p. 177-185

• Takada, M., et al., Associations between Lifestyle Factors, Working Environment, Depressive Symptoms and Suicidal Ideation: A Large-scale Study in Japan. Industrial Health, 2009. 47(6): p. 649-655

• Ostry, A., et al., The impact of psychosocial work conditions on attempted and completed suicide among western Canadian sawmill workers. Scand J Public Health, 2007. 35(3): p. 265-71.

• Feskanich, D., et al., Stress and suicide in the Nurses' Health Study. J Epidemiol Community Health, 2002. 56(2): p. 95-8.

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