**1. Introduction**

Lawyers contemplate suicide (suicidal ideation) at an exceedingly high rate. Suicidal ideation, defined as thoughts, ideas, or ruminations about ending one's own life, is the first step to suicide and is predictive of suicide attempts [1,2]. Prior estimates suggest that between 10 and 12 percent of lawyers in the U.S. have contemplated suicide [3–5], compared to 4.2% of adults ≥ 18 years of age in U.S. population [6]. Given the high rates of suicidal ideation among lawyers, it is crucial to identify factors that potentially contribute to their suicide risk.

Lawyers are prone to mental health issues, including anxiety, depression, and substance abuse [3,7], which are strongly linked to suicide risk [8–12]. A nationwide study of ~13,000 lawyers indicated that 28% experienced depression, 19% reported anxiety, 21% had alcohol use problems, and 11% had problems with drug use [3]. Lawyers also experience elevated levels of stress (i.e., perceiving events in one's life or work as unpredictable, uncontrollable, and/or overloaded) [13,14] and loneliness (perceiving one's social needs as not being met) [15–17] which are well-established predictors of suicide risk [18–24]. However, the relative contribution of lawyer mental health, stress, and loneliness to suicide risk has yet to be examined.

Work-related hazards specific to the legal profession may also contribute to suicide risk. For example, lawyers are expected to work long hours, meet tight deadlines, and handle complex legal issues, all while maintaining a high level of professionalism and client satisfaction [5,13,25,26]. This can lead to burnout and feelings of being overwhelmed, which have been linked to increased risk of suicidal ideation [27–35]. Findings from other research, however, demonstrate that the association between job burnout and suicidal ideation disappears after adjusting for depression [36]. This highlights the importance of accounting for psychological distress when seeking to identify workplace predictors of suicidality.

**Citation:** Krill, P.R.; Thomas, H.M.; Kramer, M.R.; Degeneffe, N.; Anker, J.J. Stressed, Lonely, and Overcommitted: Predictors of Lawyer Suicide Risk. *Healthcare* **2023**, *11*, 536. https://doi.org/10.3390/ healthcare11040536

Academic Editors: Athanassios Tselebis and Argyro Pachi

Received: 9 January 2023 Revised: 3 February 2023 Accepted: 5 February 2023 Published: 11 February 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Work-family conflict, or difficulty balancing work and family responsibilities, is a common stressor that can negatively impact mental health [37–40] and there is a growing body of research indicating that work-family conflict is a predictor of suicidal ideation [41,42]. Anker and Krill found that work-family conflict among lawyers was significantly associated with perceived stress and attrition due to burnout in a large sample of lawyers. These findings suggest that work-family conflict may also play a role in suicidal ideation among lawyers.

According to the World Health Organization, men are three times more likely than women to die by suicide even though women tend to experience higher levels of suicidal ideation [43]. Gender differences in suicide risk factors have also been observed across a range of occupational groups [30,44–46]. In relation to lawyers specifically, Anker and Krill (2021) [7] found that women lawyers were more likely to experience moderate to severe levels of work–family conflict, work overcommitment, perceived stress, anxiety, depression, and risky or hazardous levels of alcohol use compared to male lawyers. Owing to their higher prevalence of suicidality risk factors, we hypothesized that women lawyers may be at a higher risk for suicidal ideation than men.

Considering how many lawyers contemplate suicide and the paucity of data examining the relationship between their suicidal ideation and the known risk factors they often experience, further research on the subject is an overdue and essential step in the development of effective suicide prevention strategies tailored to that population. As such, the current study examined the relationship between suicidal ideation, and factors that negatively and disproportionally affect lawyers, including perceived stress, loneliness, work overcommitment, work-family conflict, alcohol use, and prior mental health diagnosis.

### **2. Materials and Methods**

#### *2.1. Participants*

#### Recruitment and Random Selection

The University of Minnesota Institutional Review Board reviewed the study design and protocol. Recruitment was coordinated in collaboration with the California Lawyers Association ("CLA"), a nonprofit, voluntary organization that includes the Sections of the State Bar of California and the California Young Lawyers Association, and the D.C. Bar, the largest unified bar in the United States and an organization which provides an oversight structure to maintain ethical standards and Rules of Professional Conduct. An advertisement was included in newsletters sent by the D.C. Bar and CLA to their respective member lists and posted on their organization's website. The advertisement provided a summary of the study, indicating that the survey was anonymous and that members would be randomly invited to participate in the study via email. Participants were randomly selected from a list of unique de-identified I.D.s supplied by the CLA and D.C. Bar. Each list contained approximately 98,000 IDs (196,000 total IDs). Hence, 40,000 IDs were randomly selected from each list (80,000 total) using the random sample function in the statistical platform R. From that sample, 5292 participants consented to the survey and about 4000 completed the survey. An email notification was sent to randomly selected D.C. Bar and CLA members on behalf of the researchers. Seven days following the email notification, study candidates received an email containing a link to a REDCap (Research Electronic Data Capture) survey. Clicking on the link directed participants to the survey's informed consent page. The study was conducted during the summer of 2020.

#### *2.2. Materials*

#### 2.2.1. Descriptive Variables

Demographics and work context. Information regarding age, race, relationship status, and whether respondents had children was collected. Additionally, information on the following work-related variables was collected from participants: the average number of hours worked per week, current position in the legal profession, and whether the current position involved litigation.

#### 2.2.2. Measures

Mental Health Diagnoses. Participants were asked if they ever (lifetime) or currently (past 12 months) had a diagnosis of major depression, anxiety disorder, PTSD, bipolar disorder, alcohol use disorder, substance use disorder, or a non-specified mental health disorder.

Depression. Participants completed the Patient Health Questionnaire-9 (PHQ-9) to assess the prevalence and severity of symptoms of depression [47]. For the PHQ-9, participant depression severity scores were grouped across the following 5 categories: None/Minimal (0–4), Mild (5–9), Moderate (10–14), Moderately Severe (15–19), and Severe (20–27).

Stress. The total score on the Perceived Stress Scale (PSS) was used to assess how unpredictable, uncontrollable, and overloaded respondents found their lives [48]. Scores on the PSS were grouped into Low (0–13), Moderate (14–26), and Severe (27–40) categories for analyses comparing.

Alcohol Use Severity. Scores on the Alcohol Use Disorders Identification Test (AUDIT-C) were used to assess risky drinking (women ≥ 3; men ≥ 4) and high-risk/hazardous drinking (women ≥ 4; men ≥ 5) [49].

Substance Use Severity. Scores on the DAST were used to assess substance use severity and were classified into the following four severity groups: Lifetime abstinence, No problems reported, Low, and Moderate to Severe [50].

Loneliness. Participants completed a 3-item questionnaire adapted from the Revised University of California, Los Angeles (UCLA) Loneliness Scale to assess the prevalence and severity of loneliness [51]. The questionnaire consisted of the following 3 items: "How often do you feel that you lack companionship?", "How often do you feel left out?", and "How often do you feel isolated from others?". Participants responded with "hardly ever or never", "some of the time", and "often". Ratings were summed to produce a loneliness score ranging from 3 to 9, with a higher score indicating greater loneliness. Following methods by Steptoe et al., (2013) [52], participants scores were summed and grouped across 2 categories (Lonely (3–5) and Not Lonely (6–9).

Work Overcommitment. We used the overcommitment subscale of the Effort–Reward Imbalance (ERI) Questionnaire [53] to assess feelings of being overwhelmed by work demands. Responses on the subscale were on a four-point Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree).

Work-Family Conflict. The degree to which work interfered with family life was assessed using three items from the Work-Family Conflict (WFC) subscale from the short version of the Copenhagen Psychosocial Questionnaire [54]. Participants rated items are 4-point Likert-scale ranging from 1 (no, not at all) to 4 (yes, certainly).

#### 2.2.3. Outcome Variables

Suicidality/Suicidal Ideation. Participants were classified as endorsing suicidality according to item 9 of the PHQ-9, which can accurately identify individuals at-risk for suicide attempts and death [2,55–58]. Moreover, assessing suicidal ideation with the PHQ-9 allowed for a direct comparison to recent reports of the frequency of suicidality in the legal profession [4]. Participants were considered to have endorsed suicidality if they selected "Several days", "More than half the days", or "Nearly every day" to the item "How often have you had thoughts that you would be better off dead, or of hurting yourself". Participants who selected "Never" for this item were classified as not having suicidality.

#### *2.3. Data Analysis*

Demographic and mental health severity scores on the PHQ-9 were compared between men and women using chi-square analyses. Logistic regression analyses were performed to identify associations between predictor variables (e.g., Work–Family Conflict, Work Overcommitment,) and the outcome variables (PHQ-9 suicidality) while controlling for covariates (e.g., COVID-19 impact on PHQ-9 items).

Predictors were entered one at a time in a stepwise fashion, and their impact on the model's overall fit was assessed. Those that significantly contributed to the model were entered into the primary study model. A sensitivity analysis was then conducted to examine the impact of COVID-19 on the primary model by entering a variable representing COVID-19 impact on PHQ-9 suicidality (e.g., a single item added at the end of assessments that asked whether problems defined in the PHQ-9 increased, decreased, or stayed the same since COVID-19). P-values for multiple comparisons were corrected using Holm– Bonferroni adjustments.

#### **3. Results**

Of the 80,000 members of the CLA and D.C. Bar that were randomly selected and received a study invitation, 5292 consented. The sample was restricted to lawyers who were employed part- or full-time in a legal setting at the time of the survey and who had complete data on the study measures. The final sample consisted of 1962 participants.

#### *3.1. Descriptive Results*

## 3.1.1. Frequency of Suicidal Ideation

Approximately 8.5% (N = 165) of the participants reported thoughts they would be better off dead, or of hurting themselves "Several days", "More than half the days", or "Nearly every day" and were grouped in the suicidal ideation group. The remaining 91.5% (N = 1797) selected "Not at all" for PHQ-9 item 9 and were grouped in the non-suicidal ideation group.

#### 3.1.2. Demographic Variables

Groups were compared on demographic, occupation, and mental health variables prior to model testing. Women comprised approximately 51% (N = 991) of the sample. Table 1 shows the distribution of demographic variables for participants who endorsed PHQ-9 suicidality vs. those who did not ("Not at all"). There were no differences in the proportion of men and women who endorsed suicidality as a function of gender or race. However, with respect to age, lawyers who endorsed (vs. did not endorse) suicidality tended to be younger. For example, a significantly greater proportion of lawyers from the suicidality group (compared to the non-suicidality group) belonged to the two youngest age groups (30 or younger and 31–40) and a lower proportion of suicidality endorsers belonged to the oldest age group (61 or older).

**Table 1.** Demographics according to endorsement of PHQ-9 suicidal ideation (N = 1962).


Within each row, each superscript letter denotes column proportions that did not differ significantly at the 0.05 level according to Pearson Chi-Square tests.

#### 3.1.3. Work-Related Demographics

Work-related sample demographics are shown in Table 2 for both groups. The total number of hours worked in a week, the participant's law practice setting, and whether the participant's legal position involved litigation did not significantly differ between groups. There was a trend that approached but did not reach significance (*p* = 0.051) with regards to position in the legal profession, such that a greater proportion of lawyers in the most junior level (junior associate) endorsed (vs. did not endorse) suicidality.

**Table 2.** Work-related demographics of the study sample according to endorsement of PHQ-9 suicidal ideation (N = 1962).

