Work-related suicide: Evolving understandings of etiology & intervention.

Previously published analyses of suicide case investigations suggest that work or working conditions contribute to 10%-13% of suicide deaths. Yet, the way in which work may increase suicide risk is an underdeveloped area of epidemiologic research. In this Commentary, we propose a definition of work-related suicide from an occupational health and safety perspective, and review the case investigation-based and epidemiologic evidence on work-related causes of suicide. We identified six broad categories of potential work-related causes of suicide, which are: (1) workplace chemical, physical, and psychosocial exposures; (2) exposure to trauma on the job; (3) access to means of suicide through work; (4) exposure to high-stigma work environments; (5) exposure to normative environments promoting extreme orientation to work; and (6) adverse experiences arising from work-related injury or illness. We summarise current evidence in a schema of potential work-related causes that can also be applied in workplace risk assessment and suicide case investigations. There are numerous implications of these findings for policy and practice. Various principle- and evidence-based workplace intervention strategies for suicide prevention exist, some of which have been shown to improve suicide-prevention literacy, reduce stigma, enhance helping behaviours, and in some instances maybe even reduce suicide rates. Prevailing practice in workplace suicide prevention, however, overly emphasises individual- and illness-directed interventions, with little attention directed to addressing the working conditions that may increase suicide risk. We conclude that a stronger emphasis on improving working conditions will be required for workplace suicide prevention to reach its full preventive potential.

Impact of informal caregiving on depressive symptoms among a national cohort of men.

BACKGROUND: There is evidence that unpaid caregiving can have negative effects on the mental health of female caregivers; however, evidence of impacts on male caregivers is limited. This study addressed this gap by examining associations between becoming a caregiver and depressive symptoms among men. METHODS: We used data from waves 1-2 (2013, 2016) of the Longitudinal Study of Australian Male Health (Ten to Men). Effects of incident caregiving on depressive symptoms were estimated using augmented inverse probability treatment weighting, with adjustment for potential confounders. Incident caregiving was assessed as a binary variable (became a caregiver vs not), and depressive symptoms were measured using the Patient Health Questionnaire (moderate to severe depressive symptoms; yes, no). Main analysis was prospective, drawing on wave 1 (caregiving) and wave 2 (depressive symptoms), and sensitivity analyses modelled cross-sectional associations. RESULTS: In the main analysis, incident caregiving in wave 1 was associated with depressive symptoms in the subsequent wave, with an average treatment effect of 0.11 (95% CI 0.06, 0.17) and equating to a risk ratio of 2.03 (95% CI 1.55, 2.51). Associations were robust to several sensitivity analyses, with cross-sectional associations supporting the main prospective analyses. CONCLUSION: These results provide evidence of the association between caregiving and depressive symptoms among male caregivers. This has important implications for policy and support programmes. As we seek to shift caregiving responsibilities toward a more gender-equal distribution of care, policy must recognise that, like female caregivers, male caregivers also experience mental health impacts related to their caregiving role.

Time use, time pressure and sleep: is gender an effect modifier?

BACKGROUND: The gendered division of labour contributes to differences in the way time is spent and experienced by women and men. Time spent in paid and unpaid labour is associated with sleep outcomes, therefore, we examined (i) the relationships between time use and time pressure, and sleep, and (ii) whether these relationships were modified by gender. METHODS: Adults from the Household Income and Labour Dynamics in Australia survey were included in the analysis (N = 7611). Two measures of time use (total time commitments, ≥50% of time spent in paid work) were calculated based on estimates of time spent in different activities. One measure of time pressure was also included. Three sleep outcomes (quality, duration and difficulties) were examined. Logistic regression and effect measure modification analyses were employed. RESULTS: Total time commitments were associated with sleep duration, whereby more hours of total time commitments were associated with an increase in the odds of reporting <7 h sleep. Gender was an effect modifier of the association between ≥50% of time spent in paid work and (i) sleep duration on the multiplicative scale, and (ii) sleep difficulties on the multiplicative and additive scales. Men who spent <50% of time in paid work reported more sleep difficulties than men who spent ≥50% of time spent in paid work. Feeling time pressured was associated with poor sleep quality, short sleep duration and sleep difficulties. CONCLUSIONS: Time use and time pressure were associated with sleep, with some effects experienced differently for men and women.

A blended face-to-face and smartphone intervention to improve suicide prevention literacy and help-seeking intentions among construction workers: a randomised controlled trial.

PURPOSE: In Australia and elsewhere, suicide rates among construction workers remain high. Construction workplaces are thus an important setting for targeted suicide prevention programs. This study aimed to compare suicide prevention literacy and help-seeking intentions among participants receiving face-to-face suicide prevention training, with those receiving face-to-face training augmented by a smartphone application. METHODS: A two-arm randomised controlled trial of a smartphone suicide prevention intervention was conducted among construction workers in four Australian states (trial registration number: ACTRN12619000625178). All participants received face-to-face training and were randomised to the control condition (face-to-face only, n = 575), or MATESmobile condition (face-to-face + smartphone application, n = 509). Surveys administered at baseline and 3-month follow-up measured suicide prevention literacy and help-seeking intentions for personal/emotional problems and suicidal thoughts. A mixed-model repeated measures (MMRM) analysis included all 1084 randomised participants. RESULTS: Outcomes did not differ significantly for suicide prevention literacy, nor help-seeking intentions from formal sources, informal sources outside the workplace, or no one (did not intend to seek help from anyone). However, relative to those in the control condition, those in the MATESmobile group showed greater increase in help-seeking intentions for emotional problems from a MATES worker/Connector (mean difference 0.54, 95% CI 0.22-0.87) and help-seeking intentions for suicidal thoughts from a workmate (mean difference 0.47, 95% CI 0.10-0.83) or MATES worker/Connector (mean difference 0.47, 95% CI 0.09-0.85). CONCLUSION: Results indicate that the MATESmobile application, together with face-to-face training, is beneficial in enhancing help-seeking intentions from MATES workers/Connectors and workmates to a greater extent than face-to-face training only. While this research provides some evidence that smartphone applications may support suicide prevention training, further research is needed.

Use of Parental Disability Trajectories to Identify Adolescents Who are Young Carers.

Being a young carer can have significant impacts on the lives of children and adolescents. Identifying young carers is difficult, making the provision of support challenging for service providers. This sample contained 4464 Australian children/adolescents across 11 years (49% female, aged 6/7 years at baseline, and 16/17 years at final wave). Group-based trajectory modeling was applied to examine parental disability trajectories across 5 waves of data collection. Associations between estimated trajectories and unpaid/informal caring at age 16/17 years were then assessed. Three trajectory groups were identified: consistently-low (80%), low-increasing-high (10%) and moderate-high (10%) levels of parental disability. There was strong evidence that caring was elevated in the low-increasing-high group compared to the consistently-low group, and moderate evidence of elevation in the moderate-high group. By identifying adolescents with increased odds of becoming young carers, this study shows that parental disability may be an important way for service providers to identify and support young carers.

Associations between workers' compensation and self-harm: A retrospective case-series study of hospital admissions data.

Background: While workers' compensation schemes aim to assist and support injured workers, there is some evidence that the process of pursuing a compensation claim may be extremely stressful for workers. This research aimed to compare hospital admissions for self-harm among workers' compensation claimants and non-claimants. Methods: A retrospective case-series design, this study used hospital admissions data for 42,567 patients (2011-2018) to estimate rates of hospital admission for intentional self-harm and 'self-harm and probable self-harm' (due to intentional self-harm, poisoning, or undetermined intent) and compare these between workers' compensation claimants and non-claimants. Rates were stratified by gender and calculated for each age group. Findings: For males, there was no observable difference between claimants and non-claimants for admission due to intentional self-harm. For female claimants, the incidence rate for admission for intentional self-harm was higher than non-claimants (rate ratio (RR) 2.4, 95%CI 1.8-3.2, risk difference (RD) 47.7 per 100,000 person-years). For the combined category of 'self-harm and probable self-harm', the incidence rate was elevated in both male (RR 5.8, 95%CI 5.0-6.6, RD 167.7 per 100,000 person-years) and female workers' compensation claimants (RR 3.4, 95%CI 2.8-4.2, RD 114.8 per 100,000 person-years) relative to non-claimants. Interpretation: Female workers' compensation claimants appear to have elevated rates of admission for intentional self-harm and 'self-harm and probable self-harm' compared to non-claimants. Male claimants appear to have increased rates of hospital admission for 'self-harm and probable self-harm'. This suggests that the process of pursuing workers' compensation may be associated with increased risk of self-harm, and highlights a need for further research. Funding: Suicide Prevention Australia Innovation Grant.

Employment and disability among young Australians and associations with psychological distress during the COVID-19 pandemic.

Background: Emerging global data indicates that the employment status and mental health of young people is being adversely impacted by the COVID-19 pandemic. However, little research has focused on young people with disabilities, despite their lower pre-pandemic employment rates and poorer mental health. We quantified the association between employment status and mental health among young Australians, and tested for effect modification by disability status. Methods: Linear regression analysis of Wave 9 (October-December 2020) of the Longitudinal Study of Australian Children (LSAC) assessing the association between employment status (employed, unemployed) on psychological distress (Kessler-10) and including an interaction term for employment status and disability. Results: The association between employment status and psychological distress differed by disability status. Young adults with disabilities had higher adjusted mean K10 scores indicating greater psychological distress both when they were employed (mean 22.99, 95% CI 21.41, 24.58) and unemployed (mean 29.19, 95% CI 25.36, 33.03) compared to their peers without disabilities (employed mean 18.72, 95% CI 17.75, 19.70; unemployed mean 20.45, 95% CI 18.60, 22.29). Conclusion: Young Australians in general may benefit from additional supports to improve their employment and mental health outcomes. Young people with disabilities may particularly benefit from targeted supports to gain and maintain employment and improve mental health.

Trajectories of disability throughout early life and labor force status as a young adult: Results from the Longitudinal Study of Australian Children.

OBJECTIVES: Young people with disabilities have poorer labor force outcomes than their peers without disabilities. These understandings, however, are largely based on research assessing disability at one time point only, an approach that potentially obscures variation in disability over time. We aimed to identify trajectories of disability during childhood/adolescence and assess associations between trajectory membership and labor force status in young adulthood. METHODS: We conducted group-based trajectory modeling of disability status information from six waves [waves 2-7 (age 4/5 to 16/17 years)] of the Longitudinal Study of Australian Children. The trajectories were used to predict labor force participation (employed, unemployed, not in the labor force) at wave 8 (18/19 years), adjusted for confounders. RESULTS: We identified four trajectory groups of the prevalence of disability: low (75.5% of cohort), low increasing (9.7%), high decreasing (10.9%), and consistently high (3.9%). Individuals in the low increasing trajectory were nearly three times as likely to be unemployed at age 18/19 years compared to individuals in the low trajectory [risk ratio (RR) 2.96, 95% confidence interval (CI) 1.94-4.53]. Individuals in the consistently high trajectory had a greater RR of not being in the labor force at age 18/19 years compared to individuals in the low group (reference) (RR 3.65, 95% CI 2.21-6.02). CONCLUSIONS: Results suggest that prolonged and increasing experiences of disability among young Australians may be differentially associated with future labor force outcomes. Additional support to prepare young people for the labor force should focus on individuals who consistently or increasingly report a disability.

Gender Equality and Health in High-Income Countries: A Systematic Review of Within-Country Indicators of Gender Equality in Relation to Health Outcomes.

Background: Gender equality is recognized as an important political, social, and economic goal in many countries around the world. At a country level, there is evidence that gender equality may have an important influence on health. Historically gender equality has mainly been measured to allow for between-country, rather than within-country comparisons; and the association between gender equality and health outcomes within countries has been under-researched. This article thus aimed to systematically review within-country indicators of gender equality in public health studies and assess the extent to which these are related to health outcomes. Materials and Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach with two independent reviewers. Results: Data from the eight included studies revealed that there was heterogeneity in the way gender equality has been measured as a multidimensional construct. Associations between gender equality and a number of different health outcomes were apparent, including mortality, mental health, morbidity, alcohol consumption, and intimate partner violence, with gender equality mostly associated with better health outcomes. Conclusions: Further investigation into the effects of gender equality on health outcomes, including a clear conceptualization of terms, is critical for the development of policies and programs regarding gender equality.

COVID-19 and suicide risk in the construction sector: preparing for a perfect storm.

AIMS: Worldwide, construction industries are considered to be key economic pillars of the societies they serve, and construction workers constitute a sizeable proportion of the global paid workforce. In many parts of the world, construction workers are at elevated risk of suicide. Here, we examine the extent to which construction workers may be differentially exposed to the economic effects of COVID-19. METHODS: A narrative review and synthesis of the literature was conducted. RESULTS: The economic and labour market shock resulting from the COVID-19 pandemic has led to a convergence of factors that may significantly exacerbate suicide risk among construction workers, particularly among those with lower skills. CONCLUSIONS: With important insights from previous financial crises, it is vital that governments, industry and workplaces act rapidly to mitigate suicide risk among vulnerable groups such as construction workers. Mental healthcare investment is needed, and must be complemented by prevention and control in the workplace and in the general community. Anticipating, preparing and acting to ameliorate this risk, particularly among low skilled construction workers, will save many livelihoods, as well as lives.

Suicide in welfare support workers: a retrospective mortality study in Australia 2001-2016.

OBJECTIVES: Employees working in the welfare and healthcare industry have poorer mental health than other occupational groups; however, there has been little examination of suicide among this group. In this study, we examined suicide rates among welfare support workers and compared them to other occupations in Australia. METHODS: We used data from the National Coroners Information System to obtain suicide deaths between the years 2001 and 2016. Using the Australian standard population from 2001 and Census data from 2006, 2011 and 2016, we calculated age-standardised suicide rates and rate ratios to compare suicide rates across different occupational groups. RESULTS: Overall, the age-standardised suicide rate of welfare support workers was 8.6 per 100 000 people. The gender-stratified results show that male welfare support workers have a high suicide rate (23.8 per 100 000 people) which is similar to male social workers and nurses (25.4 per 100 000). After adjusting for age and year of death, both males (rate ratio 1.48, 95% CI 1.23 to 1.78) and female welfare support workers (rate ratio 1.49, 95% CI 1.20 to 1.86) have higher suicide rate ratios compared with the reference group (excluding occupations from the comparison groups). CONCLUSION: The age-standardised suicide rates of male welfare support workers are comparable to occupations which have been identified as high-risk occupations for suicide. Both female and male welfare support workers are at elevated risk of suicide compared with other occupations. Further research is required to understand the drivers of the elevated risk in this group.

The double burden of poverty and marital loss on the mental health of older Australian women; a longitudinal regression analysis using 17 annual waves of the HILDA cohort.

PURPOSE: Compared to men, older women have poorer mental health and are more vulnerable to poverty, especially when living alone. However, few studies have examined how gender, marital status and poverty are inter-related and are associated with mental health. This study examines the gendered associations between relative poverty, marital status and mental health in older Australians. METHODS: Drawing on 17 waves of the HILDA Survey, fixed-effects longitudinal regression analysis was utilised to examine the association between: (1) relative poverty (< 50% median household income) and mental health (MHI-5); (2) marital status and poverty, in a cohort of Australians aged 65 + years. We then examined effect modification of the association between relative poverty and mental health by marital status. RESULTS: Within-person associations, stratified by gender, showed that women in relative poverty reported poorer mental health than when not in relative poverty, however no association was observed for men. Being divorced/separated was associated with increased odds of relative poverty for women, but not men. Widowhood was strongly associated with relative poverty in women, and also among men, albeit a smaller estimate was observed for men. There was no evidence of effect modification of the relationship between relative poverty and mental health by marital status for either men or women. CONCLUSION: This study provides evidence that relative poverty is a major determinant of mental health in older Australian women. Addressing gender inequities in lifetime savings, as well as in division of acquired wealth post marital loss, may help reduce these disparities.

Gendered associations between household labour force participation and mental health using 17 waves of Australian cohort data.

PURPOSE: There is some evidence that employed women report more time pressure and work-life penalties than employed men and other women; however little is known about whether this exerts a mental health effect. This analysis examined associations between household labour force arrangements (household-employment configuration) and the mental health of men and women. METHODS: Seventeen waves of data from the Household Income and Labour Dynamics Survey (2001-2017) were used. Mental health was measured using the Mental Health Inventory (MHI-5). A six-category measure of household-employment configuration was derived: dual full-time employed, male-breadwinner, female-breadwinner, shared part-time employment (both part-time), male full-time/female part-time (modified male-breadwinner, MMBW), and female full-time/male part-time. Using fixed-effects regression methods, we examined the within-person effects of household-employment configuration on mental health after controlling for time-varying confounders. RESULTS: For men, being in the female-breadwinner configuration was associated with poorer mental health compared to being in the MMBW configuration (ß-1.98, 95% CI - 3.36, - 0.61). The mental health of women was poorer when in the male-breadwinner configuration, compared to when in the MMBW arrangement (ß-0.89, 95% CI - 1.56, - 0.22). CONCLUSION: These results suggest that the mental health of both men and women is poorer when not in the labour force, either as a man in the female-breadwinner arrangement, or as a woman in the male-breadwinner arrangement. These results are particularly noteworthy for women, because they pertain to a sizeable proportion of the population who are not in paid work, and highlight the need for policy reform to support women's labour force participation.

Does disability modify the relationship between labour force status and psychological distress among young people?

OBJECTIVE: To examine the association between labour force status, including young people who were unemployed and having problems looking for work, and psychological distress one year later. We then assessed whether this association is modified by disability status. METHODS: We used three waves of cohort data from the Longitudinal Surveys of Australian Youth. We fitted logistic regression models to account for confounders of the relationship between labour force status (employed, not in the labour force, unemployed and having problems looking for work) at age 21 years and psychological distress at age 22 years. We then estimated whether this association was modified by disability status at age 21 years. RESULTS: Being unemployed and having problems looking for work at age 21 years was associated with odds of psychological distress that were 2.48 (95% CI 1.95 to 3.14) times higher than employment. There was little evidence for additive effect measure modification of this association by disability status (2.52, 95% CI -1.21 to 6.25). CONCLUSIONS: Young people who were unemployed and having problems looking for work had increased odds of poor mental health. Interventions should focus on addressing the difficulties young people report when looking for work, with a particular focus on supporting those young people facing additional barriers to employment such as young people with disabilities.

Health Literacy in Male-Dominated Occupations.

Low levels of health literacy are associated with poorer health outcomes. Both individual- and social-level factors have been identified as predictors of low health literacy, and men are known to have lower health literacy than women. Previous research has reported that men working in male-dominated occupations are at higher risk of accidents, injury, and suicide than other population groups, yet no study to date has examined the effect of gendered occupational contexts on men's health literacy. The current article examined the association between occupational gender ratio and health literacy among Australian males. The Australian Longitudinal Study on Male Health (Ten to Men) was used to examine associations between occupational gender ratio (measured in Wave 1) and health literacy (measured in Wave 2) across three subscales of the Health Literacy Questionnaire. Multivariable linear regression analyses were used and showed that the more male dominated an occupational group became, the lower the scores of health literacy were. Results for the different subscales of health literacy for the most male-dominated occupational group, compared to the non-male-dominated group were: ability to find good health information, (Coef. -0.80, 95% CI [-1.05, -0.54], p < .001); ability to actively engage with health-care providers, (Coef. -0.35, 95% CI [-0.62, -0.07], p = .013); and feeling understood and supported by health-care providers, (Coef. -0.48, 95% CI [-0.71, -0.26],p = < .001). The results suggest the need for workplace interventions to address occupation-level factors as an influence on health literacy among Australian men, particularly among the most male-dominated occupational groups.

Shifts in gender equality and suicide: A panel study of changes over time in 87 countries.

BACKGROUND: Increasing gender equality remains an imperative for countries and organisations worldwide, and is associated with the improved life outcomes of men and women. Unlike many health and wellbeing indicators, death by suicide is more common among men, but suicidal behaviours are more common among women. Understanding of the relationship between gender equality and suicide is inchoate, and limited to cross-sectional work. We sought to address this gap by examining within-country changes in gender equality over time, in relation to suicide rates. METHODS: Data from 87 countries for the years 2006-2016 were used in this analysis. Gender Equality was measured using the Gender Gap Index (GGI), produced by the World Economic Forum. Male and female suicide rates came from the World Health Organization. Fixed and random-effects unbalanced panel regression models were used, adjusting for: GDP/capita; population; urban/rural ratio; number of children/person;% unemployed; year. Models were stratified by gender. RESULTS: Increasing within-country gender equality was associated with a significant reduction in suicide rates for women (Coef. -7.08, 95% CI -12.35 to -1.82, p = 0.009). For men, there was insufficient evidence that increasing within-country gender equality was associated with reduced within-country suicide rates (Coef. -5.76, 95% CI -19.40 to 7.86, p = 0.403). LIMITATIONS: The reporting and collection of suicide data is known to vary across countries. CONCLUSION: There is evidence that within-country increases in gender equality are associated with significant reductions in within-country suicide-rates for women. More research is needed to understand the drivers of these associations.

Breadwinners and Losers: Does the Mental Health of Mothers, Fathers, and Children Vary by Household Employment Arrangements? Evidence From 7 Waves of Data From the Longitudinal Study of Australian Children.

In Australia, as in many industrialized countries, the past 50 years have been marked by increasing female labor-force participation. It is popularly speculated that this might impose a mental-health burden on women and their children. This analysis aimed to examine the associations between household labor-force participation (household employment configuration) and the mental health of parents and children. Seven waves of data from the Longitudinal Study of Australian Children were used, comprising 2004-2016, with children aged 4-17 years). Mental health outcome measures were the Strengths and Difficulties Questionnaire (children/adolescents) and 6-item Kessler Psychological Distress Scale (parents). A 5-category measure of household employment configuration was derived from parental reports: both parents full-time, male-breadwinner, female-breadwinner, shared-part-time employment (both part-time) and father full-time/mother part-time (1.5-earner). Fixed-effects regression models were used to compare within-person effects, controlling for time-varying confounders. For men, the male-breadwinner configuration was associated with poorer mental health compared with the 1.5-earner configuration (ß = 0.21, 95% confidence interval: 0.05, 0.36). No evidence of association was observed for either women or children. This counters prevailing social attitudes, suggesting that neither children nor women are adversely affected by household employment configuration, nor are they disadvantaged by the extent of this labor-force participation. Men's mental health appears to be poorer when they are the sole household breadwinner.