Over a century ago, Emile Durkheim (Durkheim, 1983; 1867) considered suicide as a society-determined phenomenon in which the role of work played a significant role. Durkheim argued that when working well, work fosters social relationships and offers people a place of purpose and solidarity. According to Durkheim the place of employment sets a social structure, moral values and a sense of identity for an individual — all of which helps give the individual meaning and reasons for living. When social structures like work disintegrate, the individual suffers, and sometimes suicide can be a consequence. When workers are only seen as a source of profit or an obstacle to profit, suicidal despair may result due the disconnection people feel (Waters, 2014).

Over 150 years later, employers across the United States are becoming increasingly aware of the need for and benefit of addressing mental health promotion and suicide prevention in the workplace, both from a business cost perspective and from a social responsibility perspective. Awareness has been slow to turn to action because employers are not sure where to begin, how much they need to do and when they have satisfied their ability in promoting and protecting employee wellbeing.

Recently, a team of health economists have been studying the costs of suicide and the return on investment of suicide prevention and intervention activities to workplaces and communities. For instance, Doran et al (2016) found that on average the cost of a suicide death of one male construction worker was $2.14 million, mostly due to the average 27.3 years of productive employment lost.

They also determined that for every dollar invested in suicide prevention $4.60 would be returned to society. Another study (Kinchin & Doran, 2017) measured a number of costs related to suicide and suicidal behaviors including production disturbance (e.g., value of lost production and staff turnover), human capital lost, medical costs, administrative costs (e.g., due to employer investigation), and more. They examined the costs associated with short- and long-term absences after a suicide attempt, full incapacity and fatality and found a 1.50:1 benefit cost ratio for investing in suicide prevention. They surmised that if employers were more aware of the economic consequences of the impact of suicide and suicidal behavior on their workplace, they might be more motivated to provide more mental health promotion and well-being initiatives.

Not all suicide prevention is crisis oriented; in fact, proactive efforts may even have a bigger ROI. Just like promoting heart health is less expensive that responding to the crisis of a heart attack, promoting optimal and holistic well-being makes good business sense. Rather than only focus on deficit or symptom-focused models of workplace intervention many positive psychological resources can also be cultivated like self-esteem, mastery, resilience and emotional intelligence. Well-being has clear connections to greater employee engagement, proactive work behavior, and transformational leadership (Milner & Law, 2017). All together, promoting protective factors, early intervention and effective suicide crisis response save companies money and heartache.

In 2012 the Chief Executive of France’s Telecom was forced to resign and six other executives faced legal action taken against the company following an investigation. Charges filed against the company were related to workplace bullying, harassment and toxic “management-by-terror” practices that were allegedly connected to over 80 employees’ suicide attempts or deaths. Several of the suicide notes written by those who went on to die by suicide explicitly identified

France Telecom as the sole cause for death due to “intolerable conditions” (Waters 2014, 2017). In this case, the executives reportedly mandated a number of highly disruptive practices in order to downsize the company. For instance they repeatedly transferred highly skilled workers to low level jobs and then relocated the workers, disrupting their families. The communication around these transitions was infused with guilt and fear, and pit workers against one another. These former professional technicians were often placed in humiliating situations where they needed to ask permission to use the toilet (Waters, 2014, 2017). Once questioned about the suicides (which reached a peak in 2010 with 27 deaths), the leaders resorted to concealing or denying the deaths or rationalizing them as individual anomalies to keep hidden from public view.

Around the same time another similar suicide wave emerged in a different part of the world. China’s Foxconn, a telecommunications company that supports the manufacturing of Apple products, also experienced a suicide cluster in 2010 and underwent highly public scrutiny. Here, instead of highly skilled professionals, the victims were often migrant workers displaced from their rural communities to work manual labor under poor conditions (Waters, 2017). At one point 300 workers allegedly took to the roof of Foxconn and threatened to jump unless they were treated more fairly.

Other “suicide waves” connecting work to suicidal despair have been noted in other cultures and industries including Australian miners, British bankers, Indian farmers and Japanese managers. In fact, the Japanese even have a work describing suicide from overwork — karo-jisatu — and consider the problem an urgent public health issue (Waters, 2017). In the United States we have also seen surges of highly publicized suicide deaths related to work including numerous banker deaths in 2015 (Sorkin, 2015) and a current surge in first responder suicide deaths (Hayes, 2018).

Toxic work demands and negative employee perceptions of the work environment have been historically under appreciated in the conversation about suicide prevention; however, research connects a number of job stress-related factors to risk of suicide death and attempts, even when controlling for mental health problems. “…individuals who are unsatisfied at work may perceive life as hopeless and lacking in meaning and may exhibit suicidal behavior.” (p. 781) Howard, et al, 2017

Howard, et al (2017) examined the “perceived reality” workers had about certain job design characteristics and threats to personal resources and determined that several indirectly contributed to the risk of a suicide attempt including:

• Lack of job autonomy • Lack of job variety • Work-family conflict (i.e., work demands make family responsibilities more difficult) • Family-work conflict (i.e., family demands make work role challenging) • Heightened job dissatisfaction and the feeling of being “trapped” • Work that was not meaningful or intrinsically rewarding

The increased attention to “mental health literacy” at work may in part be a deflection away from the importance of these findings. If workplaces believe that the mental health symptoms and suicide crises are only due to untreated or mistreated mental illnesses, they may be engaging in a “state of denial” about their own systemic contribution to the problem (Waters, 2017). One tactic used to minimize workplaces’ role is by medicalizing suicide as being the sole result of individual psychopathology rather than anything linked to work conditions (Waters, 2017).

Worker safety is a core value in many industries, and thus safety directors routinely pay attention to trends in workplace morbidity and mortality. Because most suicide deaths do not occur at a worksite, suicide has not historically been “on the radar” of safety professionals. When a workplace fatality happens, the cause is almost always determined to be “accidental” and a deeper investigation into intent to die is not undertaken. Because this deeper investigation is not done, the only remedy suggested is more safety training. While safety training will help those who did not intend self-harm, it will not benefit those whose death is intentional.

When we look at the fatal occupational injuries (Census of Fatal Occupational Injuries, 2017) the first two most common (transportation incidents and falls) are also common ways people think about taking their lives (Crosby et al, 1999; De Andrade & DeLeo, 2007). Thus, it is possible that some if not many of these workplace fatalities are actually suicide deaths, which then means that safety training may not be effective in preventing them.

Not all workplaces are created equal when it comes to suicide risk. In some situations, it is the demographics and risk factors of the types of workers coming into certain occupations (e.g. industries comprised of a majority of white men), in other situations it is the nature of the work that increases risk, and often it is a mixture of the two.

While self-reliance is often valued as a sign of strength and mental stability, it is paradoxically one of the strongest predictors of poor mental health and suicide risk (Labouliere, et al, 2015; Han, et al, 2017; Affleck, et al 2018; Milner, et al 2018); thus, industries that value self-reliance are often at heightened risk. Attitudes and beliefs like “I can solve my own problems” and “others do not need to worry about me” are often a major barrier to seeking support from family, peers or professionals.

Thus, it is not surprising that occupations that are male-dominated and value stoicism and traditional masculine norms like construction and extraction have the highest rates (53.2/100,000 for men) of suicide. In fact, in one study looking at suicide and occupation (Peterson, et al, 2018), 20% of the male suicide decedents from 17 states were in the construction/extraction industry. The study went on to suggest that tailored suicide prevention approaches would be needed for these types of industries — both efforts related to promoting early identification and help-seeking as well as improving working conditions.

An Australian study (Milner, et al, 2017) found that proximal risks to the construction workers’ suicide deaths included a transition in work experiences, a workplace injury resulting in pain or disability, and financial issues. The study also found that the decedent often disclosed to coworkers about suicide plans prior to death, indicating that peer support could be a life-saving intervention.

Some other industries also have unique risk factors, such as access to lethal means among law enforcement and exposure to trauma in protective services and some health services. For instance, the workplace suicide rate (suicide at the worksite) for protective service is 3.5 times greater than the overall U.S. worker rate; 84% of these suicide deaths involved firearms (Tiesman, et al 2015). Female physicians suicide deaths are 130% percent higher compared to females in other professions; male physicians risk of suicide is 40% higher than males in other professions (Schernhammer, 2004). Like with law enforcement, this disparity may result in part from greater knowledge of lethality of drugs and easy access to means. Veterinarians also have suicide rates that are significantly higher than the general population (Tomasi, et al, 2019), and some speculate this is in part due to their unique role in euthanizing animals, thereby increasing their exposure and reducing their fearlessness to death.

Another international study (Klingelschmidt, et al 2016) found that agricultural, forestry and fishing workers had higher risk and speculated that in addition to having the trait of high self-reliance, these workers were also socially isolated. These workers experienced highly physically demanding work (possibly resulting in acute and chronic pain), excessive work hours, and exposure to toxic/potentially lethal substances (i.e., pesticides). Finally, they were often at the whim of weather or economic disruption that impacted their ability to sustain profitable enterprises.

The United States is not the first country to consider developing a set of workplace suicide prevention guidelines. Canada has had a “National Standard of Canada for Psychological Health and Safety in the Workplace” since 2013 [https://www.mentalhealthcommission.ca/English/what-we-do/workplace/national-standard] and Suicide Prevention Australia published its “Work and Suicide Position Statement” in 2014 [https://www.suicidepreventionaust.org/sites/default/files/resources/2016/Work-and-Suicide-Prevention-FINAL%5B1%5D.pdf]

Canada.

National Standard of Canada on Psychological Health and Safety in the Workplace (the Standard) was sponsored by The Mental Health Commission of Canada (MHCC) and project managed by the Canadian Standards Association. This standard is free for download and has the same depth as any other workplace safety standard, although it currently remains voluntary, and does not have specific regulations attached. There is a goal of moving the Standard to become mandatory for all employers, similar to other health and safety standards. Its broad scope addresses cultural change through evaluation and implementation related to 13 psychological risk areas using a psychological health and safety management system which addresses issues upstream, midstream and downstream.

The development National Standard spanned 18 months and included 40 diverse stakeholders representing private and public employers, labor, associations, service providers, and government. This large group of stakeholders presented a challenge as a consensus model was used for all aspects of writing and review.

Following its release, resources were developed by the MHCC to assist with implementation. Many private and public organizations have developed resources and consulting programs to assist employers with implementation.

In the first four years there were over 25,000 downloads. The MHCC has a research project following organizations who are implementing the Standard with initial findings that the 75-page document is challenging to interpret and ascertain strategies for implementation.

Development cost: $475,000 with funding from Great West Life Assurance Company and Bell Canada (private) and the Government of Canada through several agencies and branches, including the Mental Health Commission of Canada (public).

(Note: Over several years prior to the Standard’s development, multiple research, public education and position documents had been disseminated that led to the development of a national Standard.)

Australia.

In Australia in 2014, suicide prevention was the focus of a position statement created by Suicide Prevention Australia, a non-governmental organization. The process included one author with input from an Advisory Board. The document is a public education and information piece that makes the business and social case for addressing suicide prevention in the workplace, with midstream and downstream directives presented. The document includes description of the issues, case examples, calls to action and resources. It is promoted through the National Mental Health Commission, a government body. There have been an estimated 10,000 downloads. There is no formal tracking or evaluation related to implementation, and indications are that the process needs to be simplified. The project cost $17,500 AUS, with funding provided under the Australian Government National Suicide Prevention Program.

Later the National Mental Health Commission and the Mentally Healthy Workplace Alliance reviewed the research and identified six key areas and strategies for creating mentally healthy workplaces.