Background

Suicide is a global health and social issue, with an estimated 800,000 people dying by suicide each year [1]. The social and psychological costs of suicide are high. For every suicide, it has been estimated that between six and 20 people, usually family members and acquaintances of those who died, are adversely affected psychologically and emotionally [1, 2]. This phenomenon has been described as ‘exposure to suicide’. It is the impact of exposure to suicide on these two professional groups–mental health professionals and first responders–that underpins this scoping review.

In this review, we are particularly interested in two groups of people, who because of their occupations, have greater exposure to suicide than the rest of the population; mental health professionals and first responders [3, 4]. As well as having greater than usual exposure to suicide, these groups are distinct from bereaved family and friends due to the professional nature of their relationship with the person who died by suicide. Mental health professionals and first responders, will in most cases, be unrelated to the person who died and be unlikely to have had a social or personal relationship with them. Yet these two groups of professionals are distinct from each other in that mental health professionals will often have established a therapeutic alliance with the person who died by suicide, while first responders will usually be unknown to the person prior to their suicide. Because the nature of the relationship with the deceased by suicide is different for mental health professionals than for first responders, we might expect the impacts of the exposure to suicide on these two groups to be different.

Mental health professionals (especially psychiatrists) and first responders themselves also have high rates of suicide [5, 6]. One of the explanations for the higher rates of suicides among these professions is their higher levels of occupational-related psychological distress, and for first responders, work-related Post Traumatic Stress Disorder (PTSD) [7]. In the literature, psychological distress is often talked about as vicarious trauma, or compassion fatigue [8]. Vicarious trauma (VT), defined as a disruption of perception and thoughts caused by the transmission of traumatic experiences when cumulatively witnessing disturbing clinical material or due to work-related emotional toll [8–11], can have both personal and professional impacts. On a personal level, VT is characterized by sleep disturbances, feelings of hopelessness, and disconnection from others [8].

One of the contributors to higher levels of psychological distress and VT among mental health professionals and first responders may be their higher exposure to suicide. A recent systematic review by [6] suggests a link between the psychological distress experienced in these occupations and higher rates of suicides. Attending suicide calls is one of the critical incidents ambulance personnel describe as leading to an emotional toll and therefore contributes to their mental health and well-being [12].

Exposure to suicide can affect first responders and mental health professionals personally and impact their professional practice. The changes in professional practice after a patient’s suicide include heightened awareness of suicide risk, reduction in confidence, and more restrictive practices, including, for nurses, increasing the level of observations and detention [13, 14]. The management of suicidal behavior in patients can present as increased vigilance when assessing suicidality, or the systematic referral of a patient to another colleague (for a second evaluation), or avoidance of treating patients at risk of suicide altogether [13, 15].

Other professional implications include the questioning of confidence in career choice, which may impact occupational retention [16, 17]. In respect of re-assessing career choices, questioning one’s career choice is not limited to health professionals, and has been observed in other professions that deal with emotionally sensitive content, for example, suicide researchers [9, 10].

For first responders, emotional impacts include high emotional labor (the process of controlling feelings according to organizational and duty demands), which has been found to be associated with increased suicidal ideation among firefighters [7]. This group of professionals is often those who first attend a suspected suicide scene, which has been described as one of the most critical and traumatic situations first responders may encounter during their work [18]. There is little discussion in the literature of strategies for managing psychological distress from exposure to suicide amongst first responders as a professional group.

While the research to date has provided some insights into the complex impacts of exposure to suicide on mental health professionals, there has been limited research on the impact of exposure to suicide on first responders. Furthermore, this literature has not been reviewed and examined together as phenomena of occupation-based exposure to suicide and its impacts. This scoping review aims to describe the current state of research in this field. The specific questions guiding this literature review are (i) what is known regarding the prevalence of exposure to suicide among mental health professionals (MHP) and first responders? (ii) what are the personal and professional impacts of exposure to suicide on mental health professionals and first responders? and, (iii) what are the gaps in the literature on exposure to suicide among first responders and mental health professionals?

Methods

A narrative scoping review was chosen due to the heterogeneity, of research, quantitative and qualitative, exploring exposure to suicide amongst MHP and first responders. Scoping reviews are similar to systematic reviews, but with different purposes, like to identify available evidence in a given field, to clarify conceptions, to exam how research is conducted in a certain topic, and to analyses and identification of research gaps [19]. Therefore, this method was the best fit for our research.

Search strategy

Databases.

Eligible studies were identified through searches in four academic databases (MEDLINE, Scopus, PsychNET, and Web of Science).

Search terms.

Two separate searches were conducted using different search terms for each professional group. For MHP, the following search terms were applied: “Psychology, Clinical Psychology, Psychotherapy, Health Personnel, Psychiatry, Health Professionals” using Booleans and MeSH terms, and “suicide, grief, bereavement, exposure, client suicide, patient suicide” and Booleans. For first responders, the following search terms were applied: “firefighters, police officers, emergency responders, paramedics” using Booleans and MeSH terms, and “suicide, grief, bereavement, exposure” and Booleans (complete search strategy on request from authors).

Eligibility criteria.

The inclusion criteria comprised of peer-reviewed research published in English in the last ten years (from June 2010 to June 2020) that examined the prevalence of exposure to suicide among MHP and/or first responders and/or its impacts on these groups.

Non-primary research articles (discussions, editorials, protocol papers, reviews, and theoretical papers) were excluded. Articles that examined exposure to suicide solely focused on instrument validation were also excluded as they reported only psychometric data.

Data chart.

The eligible papers were read full-text and data was charted independently by the first author with contributions from the other three authors. The data extraction described the authorship, year, country, population, sample size, measured aspects, reported emotional impacts, reported professional impacts, exposure to suicide prevalence, reported support sought, reported mental health outcomes, other relevant findings reported, limitations reported, and instruments used.

Study selection.

We conducted a title and abstract review on the 381 eligible papers retrieved. to exclude studies not meeting our eligibility criteria. In total, 53 articles were allocated for full-text review, and of these we excluded 28 that did not meet our eligibility criteria, leaving 25 papers for full review (see Fig 1).

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Fig 1. Prisma chart flow.

Paper selection and eligibility for the review.

https://doi.org/10.1371/journal.pone.0251038.g001

Results

Literature characteristics

The majority of the 25 eligible papers (n = 15) were quantitative, four were qualitative methods and six were both. Seven papers assessed suicide impacts among all mental health professionals (MHPs) [21–27]. A total of 11 papers assessed suicide impacts among psychiatrists and psychologists only [4, 28–37], one assessed the suicide impact on nurses [38] and one assessed exposure to suicide reactions among counselors and social workers [39]. Only five papers addressed exposure to suicide among first responders (firefighters and police) [3, 40–43]. The findings of each paper are summarized on the Table 1.

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Table 1. Literature review summaries.

https://doi.org/10.1371/journal.pone.0251038.t001

Discussion

This narrative scoping review has documented and synthesized the current state of research on the impacts of work-related exposure to suicide on MHPS and first responders as professionals in these occupations are more likely to encounter suicide and suicidal behavior than the general population.

Our review has shown that 17 out of the 25 papers used web-surveys as their method of data collection. While this method is growing in popularity, there are two key methodological limitations to its use [44]. First, unless a specific group has been sampled and the web survey distributed to individuals, then it is not possible to know the population the survey has reached. Without this information, researchers cannot be sure that the sample who have responded to the survey are representative of the population. In other words, the research findings cannot be generalized. Second, web-surveys are prone to selection bias, as respondents may select themselves into the sample. For example, those who are more interested in the subject, are health literate and have access to the internet are more likely to complete the web survey than those who are not. In the 17 studies that have used web surveys described in this review, the researchers have been able to describe the population sampled since they have included specific occupational/professional group (e.g., police officers), however self-selection remains a limitation to the generalization of the findings. This issue should be addressed in future research.

Police officers have the highest on-duty exposure to suicide, followed by firefighters, then psychiatrists, with counselors, social workers, and psychologists having the lowest exposure. No research reported patient exposure to suicide among nurses. Most of the studies were conducted in the USA (n = 7), while the other studies were conducted in the UK, Australia, Ireland, France, Belgium, Italy with no research from other countries All the papers that assessed exposure to suicide used web-surveys.

The impacts of exposure to suicide were reported in personal and professional domains for most groups. Personal impacts were examined, focused on emotional reactions, especially shock and sadness. The highest prevalence of shock and sadness was reported among MHP [4, 21, 29]. The lack of reporting on the full range of emotional impacts can be explained by a lack of qualitative research in this field which may be better suited to investigating this phenomenon due to its subjective nature. It is also noteworthy, that most of the research in this review that assessed emotional impacts used the Acute Emotional Impact Scale or an adaptation of this scale, restricting participants to reporting only the emotional items made possible in the scale (i.e. shock, sadness, guilt). A much wider range of emotional responses might be experienced, such as frustration, angst, and others, but the utilization of scales restricts the reporting and expression of such feelings.

Professional reactions described showed that increased awareness of suicide risk and suicide cues were the most common impacts on professional practice. No paper reported professional reactions among nurses, firefighters, and police, even though we anecdotally expect that nurses might change their practice after a patient’s suicide.

Qualitative studies tended to explore the coping strategies professionals used. Peer-support, although it was never defined or described, was the most common coping strategy used by all professionals, without differences between first responders and MHP.

Qualitative studies also showed that mental health professionals have an increased fear of litigation after a patient’s suicide. The critical incident review of the safety procedures taken by the professionals prior to the suicide has been reported to be a distressing event, potentially exacerbating the impacts of the exposure to suicide itself [16].

An interesting finding arising from the review is the lack of mental health and suicidality assessment of the mental health professionals themselves. No article discussed suicidality amongst mental health professionals, with PTSD and burnout being the only mental health outcomes explored. The lack of data regarding mental health outcomes makes it impossible to compare exposure to suicide impacts on mental health professionals with those on first responders. We do not have data to indicate which profession is most impacted by exposure to suicide. The lack of studies aimed at mental health outcomes after exposure to suicide also suggests that suicide researchers may not pay enough attention to suicide risk among health professionals, assuming that, as they are trained to give support in these situations, they might be better equipped to manage their emotions. However, mental health care professionals are among the occupations with increased suicide risk [5]. The recent review by Dutheil, Aubert [5] has highlighted the lack of research examining the etiology and the transition from suicide ideation to suicide attempts among health professionals. Therefore, we suggest exposure to suicide should be considered as a risk factor with more research needed to examine the link between exposure and suicidality amongst MHP and first responders.

This scoping review highlights several gaps in the research base on exposure to suicide in mental health professionals and first responders. First, there was a complete lack of research on exposure to suicide amongst paramedics and ambulance workers. Two reviews suggested that attending suicide is an emotional burden, no papers were focusing solely on exposure to suicide [12]. Furthermore, there were only two studies examining police and three examining firefighters, all from the USA. There is a need for research addressing the issue of exposure to suicide among these professionals and, that focus on its emotional and professional impacts.

Second, there is a lack of use of validated scales for assessing emotional impacts. Similar to the review of Séguin, Bordeleau [45], the papers in this review that used the Event Impact Scale or a sub-scale of it also used the instrument to set cut-offs scores to categorize clinical levels of distress or as a proxy measure to PTSD [23, 24, 27, 28, 33]. Following the discussion of Séguin, Bordeleau [45], the authors of the scale do not report any cut-off score as to categorize, therefore, the usage of the scale can lead to an inflate result of professionals being clinically distressed. Future research should use properly validated scales to evaluate emotional distress to identify those that are clinically affected and might benefit from support.

Third, our review highlights the lack of qualitative research in this area. While quantitative research enables hypothesis testing, quantitative assessment of the phenomenon and the correlations, qualitative in-depth investigations of the impacts of exposure to suicide are necessary to better understand how individuals subjectively make meaning of this experience. Questions remain, for example around what factors prevent professionals from seeking support, how the event affects their willingness to work with at-risk patients, and other concerns related to how the event impacts the professionals.

The fourth insight brought by the review is the lack of theory informing the research in this area. Only two studies [3, 40] utilized any theory to inform their inquiry or interpretation of data; Joiner’s Interpersonal theory of suicide (IPTS). This theory hypothesizes that the wish for suicide emerges from two psychological constructs–perceived burdensomeness (feeling like a burden to friends and loved ones) and thwarted belongingness (a sense of low belongingness or social alienation [46]. Joiner believes that individuals acquire the capability for suicide through a process of repeatedly experiencing painful events such as workplace exposure to suicide. The outcome of this repeated exposure to such events is the loss of the instinctual fear of death or what has often described as survival instinct. According to IPTS both direct and vicarious exposure can heighten the capability for suicide [47]. Two papers listed on our review have used the IPTS theoretical framework, utilizing the Acquired Capacity for Suicide Scale (ACSS) and the Interpersonal Needs Questionnaire (INQ) to access the theory’s constructs comparing it with the suicidality measures, such as the Suicide Behavior Questionnaire Revised SBQ-R [3, 40]. The results showed IPTS was not tested among mental health professionals’ exposure to suicide. Although they used measures derived from IPTS, no research compared the theory assumption of exposure to suicide as a possible cause of suicidality. Theoretically informed research, which focuses on understanding and not just explanation, is needed to advance our understanding of the context and risk of workplace exposure to suicide [48]. This in turn will help to inform the development of targeted evidence-based health promotion interventions in these occupations.

Our review points out the high impacts exposure to suicide has on different MHPs, with outcomes to the professionals’ mental health and well-being. Those outcomes, such as PTSD and anxiety are correlated with suicide risk [1]. Due to the lack of research on first responders and no research among paramedics and ambulance personnel, we can not draw conclusions regarding the impacts of exposure to suicide among these professionals. Moreover, exposure to suicide seems to be related to suicide risk among MHPs and first responders and should be the focus for suicide prevention protocol.

Conclusion

The scientific body of literature has focused on studying exposure to suicide among different health professionals, but less attention has been given to first responders, albeit with some limited, mainly quantitative research. Our review highlights some of the impacts exposure to suicide has on MHPs and how this can contribute to adverse mental health outcomes that are related to increased risk for suicide. The lack of research among first responders means we are unable draw any conclusions on the impacts of exposure to suicide and suicide risk in these groups, this is especially the case for paramedics. There is a need for more research on this phenomenon amongst police, firefighters, and ambulance workers/paramedics specifically, considering the fact that attending suicide scenes can increase PTSD outcomes. Further, more in-depth exploration of the impacts of exposure to suicide among MHP and first responders is necessary to understand how exposure to suicide through work impacts on personal and professional life, how it is experienced and managed, links with risks of suicide in these groups, and how this and other emotional distress might be reduced.

Supporting information