Workplace suicide prevention: a systematic review of published and unpublished activities

Abstract

There are a number of published studies on workplace suicide prevention activities, and an even larger number of activities that are not reported on in academic literature. The aim of this review was to provide a systematic assessment of workplace suicide prevention activities, including short-term training activities, as well as suicide prevention strategies designed for occupational groups at risk of suicide. The search was based on Meta-analysis of Observational Studies in Epidemiology (MOOSE) Guidelines. The databases used for the searches were the Cochrane Trials Library and PubMed. A range of suicide prevention websites were also searched to ascertain the information on unpublished workplace suicide prevention activities. Key characteristics of retrieved studies were extracted and explained, including whether activities were short-term training programmes or developed specifically for occupations at risk of suicide. There were 13 interventions relevant for the review after exclusions. There were a few examples of prevention activities developed for at-risk occupations (e.g. police, army, air force and the construction industry) as well as a number of general awareness programmes that could be applied across different settings. Very few workplace suicide prevention initiatives had been evaluated. Results from those that had been evaluated suggest that prevention initiatives had beneficial effects. Suicide prevention has the potential to be integrated into existing workplace mental health activities. There is a need for further studies to develop, implement and evaluate workplace suicide prevention programmes.

workplace suicide prevention, suicide, job stress, occupations

Introduction

Worldwide, the vast majority of suicides occur in the working age population (WHO, 1999, 2005) and many of those who die by suicide are employed at the time of death (Yip and Caine, 2011). This presents a clear motivation for workplace suicide prevention activities, especially in occupational groups at risk of suicide, such as farmers (Fuller et al., 2007), police (Mishara and Martin, 2012) and construction workers (Gullestrup et al., 2011). There are a number of citable examples of suicide prevention activities in these occupational groups (Fuller et al., 2007; Gullestrup et al., 2011), as well as in other workplace settings such as the armed forces (Knox et al., 2003, 2010). These examples of workplace suicide prevention have accompanied the growing interest in programmes to prevent mental ill-health in the workplace (LaMontagne et al., 2014) and the development of guidelines for workplace suicide prevention released by the World Health Organization (WHO, 2006).

There is one previous review on workplace suicide prevention programmes (Takada and Shima, 2010), but this was confined in scope as it only included interventions published in academic journals, thereby missing information from other sources such as ‘best practice’ registers. With this in mind, the aim of the current review was to provide a systematic evaluation of the characteristics of workplace (defined as locations where paid work is undertaken by workers for an employer) suicide prevention activities. The review search strategy targeted general training programmes applied across a number of settings, as well as prevention initiatives developed specifically for occupational groups and industries. In terms of the evaluation, the review assessed whether workplace suicide prevention activities were effective in reducing suicidal behaviours or risk factors for suicide (e.g. mental health problems), as well as improving help seeking and reducing stigma against suicide.

METHODS

The search was based on Meta-analysis of Observational Studies in Epidemiology (MOOSE) Guidelines (Stroup et al., 2000) and was conducted by the first author of the article, with checking undertaken by the other authors. The databases used for the searches were the Cochrane Trials Library and PubMed, as well as a general use search engine (Google). A range of suicide prevention websites were also searched to ascertain information on unpublished workplace suicide prevention activities. These included national suicide prevention websites such as Australia's Living Is For Everyone (LIFE) (http://www.livingisforeveryone.com.au/Home.html), Suicide Prevention Canada (http://www.suicideprevention.ca/), the Suicide Prevention Resource Center Best Practice register (http://www.sprc.org/bpr) and Mental Health Compass (https://webgate.ec.europa.eu). Information was also sought from the International Association for Suicide Prevention and the World Health Organization websites. There was no restriction placed on the time period for the review.

Search terms and strategies

Search terms used for the search were the following: suicid* AND workplace* AND prevent*; self harm AND workplace* AND prevent; suicid* AND workplace* AND train* in both academic and general search engines. Independently, suicide prevention websites were also searched to identify prevention activities undertaken in other workplace settings. If necessary, authors were contacted to identify additional details on results or methodology of retrieved studies. Following the search of the databases, a secondary search of reference lists was undertaken from within retrieved articles.

Inclusion and exclusion criteria

To be eligible for the review, prevention had to be provided to persons employed in workplaces, rather than to patients and service users, which meant that activities directed at clients or other users of services, including students in school settings, hospital patients or persons in contact with the police were excluded (e.g., Berlim et al., 2007; Botega et al., 2007). If not available in English, articles were screened out. The review considered information from both unpublished and published literatures, including abstracts, and descriptions of programmes/prevention initiatives on websites and white papers. As mentioned previously, we considered general training programmes as well as prevention initiatives developed for specific occupational or industry groups. Protocols or descriptions of prevention activities that had not actually been conducted were excluded.

Extracted information

Information extracted from each article included author names, the country and setting of the study, the main outcome of the study, the contents of the interventions and whether or not the intervention had been evaluated. For those workplace interventions that had been evaluated, information was obtained on whether these were process outcomes (e.g. whether those participating in the intervention found it acceptable), suicidal behaviours (suicide ideation, suicide attempt or suicide death) or other proximal outcomes, such as willingness to seek help for suicide, and reduction in stigma. We also extracted information on whether the prevention was general training programme or an occupational- or industry-specific programme.

RESULTS

The original search of website and academic search databases produced 212 studies or programmes. As can be seen in Figure 1, most information on workplace suicide prevention came from publically available best practice and national websites, rather than published literature. Two articles had to be screened out of the search as there was no information available in English (Kouno, 2004; Kojima and Nakamura, 2007). An additional four articles were obtained from the reference list of other articles. At the last stage, two articles were excluded due to ambiguous details about whether the programmes were provided to employees within workplaces or to service users/students (Cross et al., 2007; Cao et al., 2013). After exclusions, there were 13 interventions that remained relevant for this review.

Fig. 1:

Search process for the systematic review.

Current workplace suicide prevention activities

Table 1 presents the 13 workplace suicide prevention project programmes that met the inclusion criteria. The majority of these were set in Australia or the USA, with other examples in Japan, Canada and Brussels.

Table 1:

Description of the workplace suicide prevention studies and programmes included in the systematic review

Name	Countries	Source of information	Overview	General training or occupational-specific programme	Industry of occupational target group	Published results	Published evaluation
Suicide Prevention in the Workplace: good practices pre- and post-intervention (Forceville, 2013)	USA	Mental health compass	Education and training. Emphasis on mental health promotion and reducing access to means, special care for high-risk groups	Training package	Not specified	Nil	Nil
Working Minds: suicide prevention in the workplace (Spencer-Thomas, 2013)	USA	Best practice register SPRC	Education and training aimed at administrators and employees. The programme provides advice for what to do when a person is acutely suicidal, gatekeeper training and training regarding postvention	Training package	Not specified	Nil	Nil
US Air Force Suicide Prevention Program (Knox et al., 2003, 2010)	USA	Best practice register	Training and community awareness and education-aimed suicidal risk detection, assessment and support facilitation. Includes policy change	Occupational-specific programme	Air force	Yes	Yes
In Harm's Way: law enforcement suicide prevention (Bureau of Justice Assistance, 2013)	USA	Best practice register	Train the trainers programme that provides a comprehensive approach to stress management and suicide prevention for law enforcement and correction professionals	Occupational-specific programme	Police	Nil	Nil
Applied Suicide Intervention Skills Training (ASIST) (LivingWorks, 2013)	USA	Best practice register	Teaching gatekeepers suicide first aid to help a person at risk stay safe and seek further help as needed	Training programme	Not specified	Nil	Nil
Post Traumatic Stress Management/Psychological First Aid Workshop (PTSM/PFA) and Recognizing Depression and Suicide Risk (Riverside Trauma Center, 2013)	USA	Riverside Trauma Center	How to assist employees following the suicide of a co-worker, and training on how to recognize the signs and symptoms of depression and suicide	Training programme	Not specified	Nil	Nil
Army G-1 Suicide Intervention Program (Office of the Deputy Chief of Staff, 2013)	USA	Best practice register	Teaching soldiers to recognize those at risk, to help a person at risk stay safe and seek further help as needed	Occupational-specific programme	Army	Nil	Nil
OzHelp Foundation (OzHelp Foundation Ltd, 2013)	Australia	Life communications	Education and training aimed at administrators and employees. Targeted at blue-collar workers	Training programme for blue-collar workers	Multiple	Nil	Nil
IncoLink (Incolink, 2009, 2013)	Australia	Life communications	Education and training aimed at apprentices	Training programme	Construction	Yes	Yes
Farm-link (The NSW Centre for Rural and Remote Mental Health, 2013)	Australia	Life communications	Training and education	Occupational-specific programme	Agriculture	Nil	Nil
Mates in Construction (Gullestrup et al., 2011)	Australia	Life communications	Education and training aimed at all construction workers, involves a buddy system and training gatekeepers	Occupational-specific programme	Construction	Yes	Yes
Together for Life (Mishara and Martin, 2012)	Canada	(Mishara and Martin, 2012)	Education and training. Multi modal suicide prevention campaign in the police force	Occupational-specific programme	Police	Yes	Yes
Employee Assistance Programmes (Nakao et al., 2007)	Japan	(Nakao et al. 2007)	Counselling, education and awareness	Occupational-specific programme	Information service company	Yes	Yes

The review included a number of stand-alone, short-term training programmes, such as ‘Working Minds’, which provides training within workplaces on risk recognition and referral options. Working Minds uses a Theory of Stages of Change model to assess readiness to change and engage in suicide prevention activities (Spencer-Thomas, 2013). This type of prevention initiative uses a ‘train the trainer’ format aiming to increase the knowledge and skills of people within organizations to recognize and response to suicide or mental health problems; for example, equipping managers in workplaces with the required skills to recognize and respond to suicidality among employees.

Other training packages that have been used in workplace settings include the ‘Applied Suicide Intervention Skills Training’ (an international programme to teach competencies to intervene with persons at risk of suicide) (LivingWorks, 2013), Suicide TALK (a short awareness programme aimed at addressing stigma and increasing knowledge), Safe TALK (to recognize people with thoughts of suicide and how to link them with suicide intervention resources) and the Question Persuade Refer (QPR) programme, which is designed to teach workplace ‘gatekeepers’ to recognize the warning signs of a suicide crisis and refer someone at risk (Cross et al., 2007). The QPR approach has been used in an Employee Assistance Program (EAP) that sought to provide suicide prevention and intervention training for professional white-collar workers in Japan (Nakao et al., 2007). A smaller number of training programmes addressed suicide bereavement in the workplace (Bureau of Justice Assistance, 2013; Forceville, 2013; Riverside Trauma Center, 2013).

The review search strategy also identified suicide prevention initiatives for ‘high risk’ industries or occupations. To name a few, these included IncoLink (an Australian program aimed at apprentices in the construction industry in Victoria) (Incolink, 2013), Farm-link (an Australian suicide prevention for farmers) (The NSW Centre for Rural and Remote Mental Health, 2013), ‘Mates in Construction’ (an Australian suicide prevention in the construction industry) (Gullestrup et al., 2011) and the ‘OzHelp Foundation’ suicide prevention training for the building, construction and mining industries, the utilities industry, community services and private and public service sectors (OzHelp Foundation Ltd, 2013). Other examples include the US Air force suicide prevention programme (Knox et al., 2010), Army ACE Suicide Intervention Program, G-1 (Office of the Deputy Chief of Staff, 2013), In Harm's Way: Law Enforcement Suicide Prevention (Bureau of Justice Assistance, 2013) and Together for Life (a Canadian police suicide prevention strategy) (Mishara and Martin, 2012). There were several military programmes in separate countries, as discussed in a recent review (Zamorski, 2011). Like the programmes mentioned above, these initiatives aimed to train ‘gatekeepers’ with the skills needed to recognize and refer suicidal persons to treatment but differed in that they had been developed to address occupational-specific risks; for example, taking an industry-wide approach working with employees and managers across different construction sites (Gullestrup et al., 2011).

Effectiveness

As can be seen in Table 1, there is a lack of information on the evaluation of workplace suicide prevention activities. This was particularly the case for general training programmes, which may have been evaluated in different settings such as schools, but not been evaluated in terms of employee–employee or employer–employee suicide prevention. Generally, evaluated initiatives were developed for specific occupational contexts using a pre–post observational design.

For example, Mishara and Martin's (Mishara and Martin, 2012) evaluation of a suicide prevention strategy among police in Canada demonstrated a noticeable decrease in suicide over an 11-year period, admittedly based on low numbers. The evaluation of the US Air Force strategy found a significant reduction in suicide over a 13-year period (Knox et al., 2010). This programme, beginning in 1996 and continuing to this day, included a range of efforts including policy changes regarding the availability of resources to those in need, an education and stigma reduction campaign and linking with community and outside health services (Knox et al., 2010). In Japan, Nakao's (Nakao et al., 2007) report on EAP service trained to connect suicidal workers with care and provide education and awareness training suggests a significant reduction in workers reporting suicide ideation at 2-year follow-up.

In terms of other evaluation outcomes, the ‘Mates in Construction’ programme reported an increase in knowledge about risk factors, stigma and help-seeking behaviour over an 18-month period in construction sites adopting the suicide prevention initiatives compared with those that did not (Gullestrup et al., 2011). Similarly, an evaluation of Inco-Link's suicide prevention activities with young apprentices in the trades industry reported an increase in knowledge about suicide risk factors, and an improvement in attitudes and help-seeking behaviours over time (Incolink, 2009).

DISCUSSION

Very few workplace suicide prevention initiatives have been evaluated in terms of effectiveness, either among those that have been developed for specific organizational contexts or those that have been developed as general training packages. Those programs that were evaluated used observational or quasi-experimental designs, which have a weaker ability to make causal inference about the role of interventions in reducing suicidality or its proximal risk factors than randomized controlled trials.

In general, most suicide prevention activities have been at the secondary and tertiary levels and aim to reduce risk and make sure help is available when it is most needed. Although undoubtedly important, these strategies fail to address factors at the primary level, i.e. modifiable risk factors for suicide in workplace settings. Those workplace risk factors found to be associated with suicide in past research studies include low control over work, monotony of work and high psychological demands (Feskanich et al., 2002; Ostry et al., 2007; Tsutsumi et al., 2007; Woo and Postolache, 2008; Schneider et al., 2011). These adverse psychosocial job stressors, and others such as job strain, low decision latitude, low social support, high psychological demands, effort–reward imbalance (i.e. high effort and low reward) and high job insecurity have also been found to predict common mental disorders across working populations in numerous studies (Bonde, 2008). Addressing these factors is increasingly being recognized as ‘best practice’ in workplace mental health and job stress interventions (Sanderson and Andrews, 2006; Martin et al., 2009; Jorm, 2012; LaMontagne et al., 2012, 2014) and has also been highlighted in the WHO guidelines on suicide prevention in the workplace (WHO, 2006). Studies tended not to discuss the extent to which workers are able to access and use lethal methods of suicide. Restricting access to lethal methods is particularly relevant for at-risk occupations, such as police and the military.

Due to a lack of available information, it is impossible to make any conclusions about the effectiveness of workplace suicide prevention. More evaluation of workplace suicide prevention initiatives is clearly needed, as are more rigorous controlled trials so suicide or its proximal outcomes are able to be assessed. This would include developing controlled trials assessing whether suicide prevention within workplaces is able to reduce suicidality (suicide ideation, attempts/self-harm and deaths) or other proximal outcomes such as help-seeking, stigma and access to means over both shorter and longer term time frames.

Acknowledging this, however, a number of the studies evaluated in this review have made suggestions as to key elements in workplace programmes. These suggestions include the importance of having a multi-faceted, comprehensive and community-based approach that simultaneously operates at a universal level while also ensuring those at risk are able to be identified and provided with treatment in a timely manner (Gullestrup et al., 2011; Knox et al., 2010; Mishara and Martin, 2012). For example, Mishara and Martin (Mishara and Martin, 2012) suggest that the implementation of a suicide prevention programme in police was greatly aided by the high regard the programme had from stakeholders. These researchers also suggest that the success of the programme was because all levels in the police force were affected and there was a general positive cultural change about how suicide was seen in the workplace. Gullestrup et al. (Gullestrup et al., 2011) highlight the role of union support in their construction industry intervention. The US Air Force programme by Knox et al. (Knox et al., 2003, 2010) also indicates the importance of reach at every level of the force, as well as the need for programmes to be responsive to changes in the work environment through ongoing monitoring. These elements align with recommendations regarding ‘best practice’ in workplace mental health interventions (Sanderson and Andrews, 2006; Martin et al., 2009; Jorm, 2012; LaMontagne et al., 2012, 2014; Woo and Postolache, 2008) and with the WHO guidelines for workplace suicide prevention (WHO, 2006).

The limitations of this review include the fact that it is likely to have missed a number of interventions as they did not have readily accessible information on Internet, as well as those that had not published their results or evaluations. Further, the review was mainly confined to English-speaking countries. Also, there were a number of pertinent factors influencing workplace suicide prevention that were not able to be addressed in this article. This particularly refers to stigma about suicide within workplace settings. Although recent evidence suggests that community stigma to suicide (Witte et al., 2010) has lessened over time, it is not know to what extent this differs across social settings. For example, whether there are differences in the extent to which individuals feel comfortable in disclosing suicide ideation to family or friends as opposed to their work colleagues. Employers may also have fears that addressing suicide could lead to copycat effects among other workers and query the extent to which it is their responsibility to implement intervention activities.

In conclusion, we found that workplace suicide prevention is currently occurring in a number of different formats and settings. While our review found some evidence suggesting that these activities had been effective in reducing suicide, we believe that prevention activities need to be evaluated across a range of different occupational settings. A pertinent question for future research and prevention is whether workplace suicide prevention is necessary only for occupational groups that are particularly at risk of suicide or whether all workplaces can benefit from prevention activities. It is also necessary to further investigate the extent to which prevention activities can be embedded within wider prevention initiatives including reducing access to means and exposure to workplace psychosocial stressors.