3.1.4. Mental health Diagnoses and Symptom Severity

There were no significant group differences concerning current drinking status (current drinker, former drinker, or lifetime abstainer). However, regarding substance use status, a significantly greater proportion of endorsers of suicidality identified as a current substance user (data not shown). Table 3 shows the proportions of lawyers in each suicidality group with a past 12-month mental health diagnosis and the proportion within the severity classifications of the PHQ-9, AUDIT-C, DAST, PSS, and the UCLA loneliness scale. Overall, a greater proportion of lawyers who endorsed suicidal ideation had a current mental health condition (Depression, Anxiety, PTSD, Bipolar Disorder, AUD, or other) and were significantly more likely to be in the moderate, moderately severe, or severe range of depression as measured by the PHQ-9. Similar results indicating greater severity among the suicidality vs. the non-suicidality group were reported concerning (1) hazardous drinking (AUDIT-C), (2) substance use severity (DAST), (3) moderate to high stress (PSS), and (4) loneliness (UCLA Loneliness Scale).


**Table 3.** The prevalence of mental health diagnoses, severity of depression, alcohol use, substance use, and loneliness in the study sample according to endorsement of PHQ-9 suicidal ideation (N = 1962).


#### **Table 3.** *Cont.*

Each subscript letter denotes a subset of whose column proportions do not differ significantly from each other at the 0.05 level.

Table 4 shows the proportion of participants in each group with responses to survey items assessing whether participants believed their time in the legal profession has been detrimental to their mental health, led to increased alcohol/substance use, or caused them to contemplate leaving the profession due to mental health, burnout, or stress. A significantly greater proportion of lawyers in the suicidality group reported that their time in the legal profession was detrimental to their mental health, caused an increase in their substance/alcohol use, and considered leaving the profession due to mental health problems or burnout.

**Table 4.** Proportion of participants with and without PHQ-9 suicidal ideation with responses to items reflecting the perceived relationship between personal mental health and time in the legal profession (N = 1962).


Each subscript letter denotes a subset of whose column proportions do not differ significantly from each other at the 0.05 level.

#### *3.2. Predictors of Suicidal Ideation*

The results of the logistic regression analyses examining predictors of endorsement of suicidal ideation among lawyers are shown in Table 5. The following predictors did not significantly contribute to the model: alcohol and substance use severity, age, and work-family conflict. As a result, these items were removed in the final, simplified model. The final model contained the following predictors: gender, history of a mental health diagnosis, loneliness, perceived stress, and work overcommitment. Results of the model indicated that the odds of having suicidal ideation were 2.2 times higher among lawyers with high work overcommitment and 1.6 times higher among lawyers with an intermediate level of work overcommitment. Lawyers who screened as lonely on the UCLA loneliness scale were 2.8 times more likely to endorse suicidality than lawyers who did not screen as lonely. Gender was also significantly associated with suicidality, with men being 2 times more likely to endorse suicidality compared to women. Lawyers with a history of at least one mental illness diagnosis were 1.8 times more likely to endorse suicidality compared to lawyers with no history of mental illness. Finally, compared to lawyers with low perceived stress, those with high or intermediate stress levels were 22 times more likely and 5.5 times more likely, respectively, to endorse suicidality.


**Table 5.** Predictors of PHQ-9 suicidal ideation among lawyers (N = 1962).

\* significant difference from referent (\*\* *p* ≤ 0.01; \*\*\* *p* ≤ 0.001); *OR* = odds ratio; *CI* = confidence interval.

#### *3.3. Sensitivity Analysis*

Accounting for COVID-19. It is important to acknowledge that data collection for the study occurred during the COVID-19 pandemic. In an attempt to control the pandemic's collateral burden on the study outcomes, responses to a single item assessing whether participants believed their PHQ-9 depression symptoms changed since the beginning of the pandemic was entered into the model as a covariate ("Thinking back to before the COVID-19 pandemic, do you believe the frequency of these problems has remained the same, decreased, or increased?"). The results of the model indicated that the perceived influence of COVID-19 on PHQ-9 responses was not a significant predictor of suicidality and that the ORs and significance levels of all the predictors noted in Table 5 were maintained (Supplement Table S1).

#### **4. Discussion**

Given the disproportionately high rates of lawyers who contemplate suicide, this study was designed to identify risks for suicidal ideation in the legal profession. To the best of our knowledge, this is the first study to report on factors related to suicidal ideation among lawyers randomly selected from a large sample of practicing lawyers. The first, most notable finding was that 8.5% of lawyers in our sample endorsed suicidal ideation as assessed by the PHQ-9, which is twice as high as the rate in in the general working population and closer to the rate among Utah lawyers (11.9%) noted by Thiese et al. (2021) [4]. The high prevalence of suicidal ideation among lawyers warrants further attention and mitigation efforts that address associated risk factors.

In addition to the high overall rate of suicidal ideation among lawyers, our study demonstrated that perceived stress was significantly associated with increased risk for suicidal thoughts. In fact, the odds of contemplating suicide were a remarkable 22 times higher among lawyers with high (vs. low) stress on the PSS. This finding supports prior studies indicating that perceived stress (as assessed by the PSS) predicts suicidal ideation and suicidal behavior in other populations [19,59,60]. However, the highly conspicuous extent to which it relates to lawyer suicide risk specifically would suggest that stress should be a primary target of suicide prevention and mitigation strategies for that population. A twofold strategy whereby stressors in lawyers' lives are reduced, and their stress tolerance is enhanced, would seem to be the most efficacious approach for mitigating the stresssuicidality risk. To date, however, most efforts to reduce stress within the legal profession have tended to target the individual, e.g., through the provision of personal stress management tools and self-care resources. Where employers have attempted to address the more structural and systemic precipitators of stress (i.e., unrealistic time pressures, unclear expectations, workload control, lack of feedback), employees have generally rated their efforts as 'highly ineffective' [5]. Simply put, it would seem the legal profession has been better at alleviating the effects of stress than in throttling the causes.

To be clear, interventions aimed at helping individuals better cope with stress should remain an essential element of any legal employer's efforts to improve lawyer mental health. Evidence-based self-care interventions for coping with perceived stress have been demonstrated to be effective in numerous settings [61–63]. Considering the profound impact of stress on lawyer suicidality, we believe that all options should remain viable for mitigating stress, including the examination and recalibration of organizational or profession-wide attitudes, norms, and cultures relating to work. Placing increased onus for change on the systems and structure of the profession, as opposed to individual lawyers, would seem appropriate due to the reported experiences of lawyers themselves. Specifically, a significantly greater proportion of lawyers who contemplated suicide indicated that working in the legal profession was detrimental to their mental health and contributed to their substance use, and feelings of burnout (See Table 4). Furthermore, such systemic introspection is both needed and timely in the wake of the COVID-19 pandemic. As noted in a recently published report on workplace mental health from the U.S. Surgeon General, organizational leaders, managers, supervisors, and workers alike have an unprecedented opportunity to examine the role of work in our lives and explore ways to better enable thriving in the workplace and beyond.

The importance of individual and organizational solutions for creating more mentally healthy workplaces is well-established in the literature [64], with upstream approaches being proposed as the most effective to prevent suicide and workplaces being ideal contexts to apply such approaches [65]. By seeking to reduce the incidence and impact of perceived stress among their lawyers, legal employers could be going far upstream with the potential for meaningful reductions in suicidal ideation. An obvious but important fact must be noted, namely that stressors outside of work could certainly contribute to lawyer suicidal ideation and therefore escape the reach of an employer's efforts to reduce stress. To speak practically, employers have an outsized role to play after numerous surveys and studies confirm that occupational pressures and fears are exceedingly the leading source of stress for American adults [66].

Social isolation or loneliness is noted as a common experience among lawyers and law students, often related to the demanding and high-stress nature of the legal profession, as well as the competitive and individualistic culture of law firms and law schools [15,16]. In the present study, lawyers experiencing high levels of loneliness were nearly three times as likely to experience suicidal ideation as those experiencing low levels of loneliness. This finding aligns with previous work demonstrating a relationship between loneliness and

suicide risk [18,20,22,23]. Importantly, research has also shown that a sense of relatedness, i.e., how you connect, or relate to others, and whether you feel a sense of belonging at work, among lawyers strongly correlates with improved wellbeing [67]. By making collaboration and regular social interactions in the work environment more of a priority, employers may be able to help mitigate some of the loneliness their lawyers experience. Any such efforts will undoubtedly be complicated by remote and hybrid working models that now predominate the legal field, especially as recent reports from the field suggest that many lawyers are reluctant to return to the office [68]. Given the high rates of alcohol misuse among lawyers and the strong connection between workplace permissiveness towards alcohol and the risk of hazardous drinking among lawyers [7], efforts to combat loneliness and isolation should avoid reliance on alcohol-based events as a primary means of increasing socialization and connection.

Turning to gender, the odds of suicidal ideation were two times higher for men than women. This surprising finding stands in contrast to the 'gender paradox of suicidal behavior' demonstrated by other research, whereby it has been shown that women in most Western countries have higher rates of suicidal ideation but lower rates of mortality than men [69,70]. This finding is also notable because women attorneys experienced higher levels of depression, anxiety, and hazardous drinking than men, which would typically suggest a higher level of corresponding suicide risk. However, after controlling for these variables in our final model, it was revealed that men were more likely to experience suicidal ideation. This would suggest that factors not included in our model, and which may not typically be tied to suicidality, are affecting the tendency of male attorneys to experience suicidal ideation. Further research would be needed to determine the specific reasons for the higher rates of suicidal ideation among male lawyers and the apparent inapplicability of the gender paradox of suicidal behavior to the lawyer population.

Relating to work overcommitment, lawyers with high (vs. low) levels of work overcommitment were two times as likely to endorse suicidal ideation, while those with intermediate levels of overcommitment were 1.5 times more likely to report such thoughts. Work overcommitment, as measured by the ERI questionnaire, has been described as an intrinsic or personality-based coping factor which reflects the need for approval, esteem, and control and it has been shown to be significantly associated with cynicism, exhaustion, and greater psychological distress [71]. According to the ERI model proposed by Siegrist and Montano, 2014 [53], overcommitment involves a desire to control one's work environment and an inability to disconnect from work. Evidence of work overcommitment includes thinking about work immediately upon waking, having people tell you that you sacrifice too much for work, and an inability to relax and switch off work, among other things. High levels of overcommitment to work have been shown to play a detrimental role in lawyer mental health [72], but interventions aimed at reducing such work overcommitment face an uphill climb in the legal profession. Being overly dedicated to one's work is generally highly rewarded in law, beginning in law school and continuing throughout many legal work environments where lawyers are often promoted based on their observed level of commitment to their work, their firm, and their clients. At the same time, research has shown that extrinsic validations and rewards (i.e., grades, rankings, honors, and financial rewards) do not predict lawyer wellbeing but instead that these external considerations that often dominate law schools and law practice are of subordinate importance to lawyer happiness when compared to other basic psychological needs, such as autonomy, relatedness to others, and competence [66]. By raising awareness of the notable downsides of being too committed to one's work, encouraging lawyers to set and maintain appropriate boundaries in their lives, and reframing notions of success to prioritize intrinsic over extrinsic rewards, stakeholders in the legal profession may be able to temper or modulate the harmful effects of work overcommitment without asking lawyers to fully abandon the dedication to their work that may have greatly contributed to elements of their prior success and achievements.

Findings from the present study are consistent with previous research linking mental health disorders (e.g., depression, anxiety) to increased risk for suicidal ideation [73,74]. For example, while suicide accounts for about 1.4% of deaths worldwide, it has been estimated that the risk climbs to 5–8% for those with a mental disorder, such as depression, alcoholism, and schizophrenia [75]. It is well established that mental health disorders can disrupt cognitive and emotional functioning, leading to negative thoughts and behaviors, including suicidal ideation [73]. The present study adds to this literature by demonstrating that these factors are also relevant in the specific context of the legal profession because lawyers with a prior mental health diagnosis were nearly twice as likely to demonstrate suicidal ideation.

Another possible explanation of heightened suicidal ideation among lawyers is workplace culture which may promote unhealthy coping mechanisms and discourage seeking help for mental health problems. Previous research has demonstrated a pronounced reluctance on the part of lawyers to disclose or seek help for a mental health disorder, often due to fear of negative career or professional repercussions [3]. This "sink or swim" mentality and stigma surrounding seeking help for mental health problems may create a toxic work environment that contributes to the high rates of suicidal ideation in the legal profession. One strategy to address this issue involves destigmatizing mental health problems and promoting a culture of help-seeking within the legal profession when mental health problems arise.

Previous research indicates work–family conflict, alcohol use (AUDIT-C), and drug use (DAST) are associated with suicide risk. However, they were not associated with contemplating suicide among our sample of lawyers. This could be due to an overlap between these factors and perceived stress or other variables in the model. For example, other research demonstrates that scores on the AUDIT-C and DAST strongly correlate with perceived stress [76]. As such, it is possible that due to the overlap and strong relationship between perceived stress, alcohol use disorder, and substance use disorder, that the predictors of AUDIT-C and DAST scores did not emerge as significant while perceived stress did. It is important to emphasize that several lines of research implicate alcohol and substance use with suicidality, while several other lines of research demonstrate that lawyers engage in hazardous levels of alcohol and substance use at rates much higher than the general population. Although risky drinking was not a significant predictor of suicidality in this study (likely for the reasons cited above), ours and other's past work clearly indicates a strong connection between problem drinking and psychological distress among lawyers. It is therefore possible that problem drinking impacts the risk for suicidal ideation among lawyers indirectly, by contributing to elements of psychological distress (e.g., perceived stress, poor mental health). Considering these findings, more research is needed to examine the specific contribution of risky drinking to suicidality among lawyers and it would be inappropriate to conclude that it does not meaningfully contribute to their suicide risk.

#### **5. Limitations**

There are limitations to the present study that should be considered when interpreting the results. First, the cross-sectional design of the study means that causality cannot be inferred. It is possible that suicidal ideation may also be a cause rather than just a consequence of the predictor variables. Longitudinal studies are needed to establish the direction of the relationship between these variables.

Second, the sample of lawyers in the present study was drawn from two jurisdictions only, California and Washington, D.C. Although those jurisdictions have among the largest lawyer populations in the United States and thereby provide for a large and diverse sample, they may not be representative of the legal profession as a whole. Further research would help confirm the generalizability of these findings to other geographic regions.

Third, the present study relied on self-report measures to assess predictor and outcome variables. Self-report measures are susceptible to bias and may not always reflect an individual's true thoughts, feelings, or behaviors. Future research using objective measures (e.g., medical records, performance assessments) may provide a clearer picture of the relationship between these variables, though such research may be difficult or impractical to conduct.

Finally, although AUDIT scores did not predict suicidal ideation in the present study, drinking is still very relevant to the discussion of suicide in this population given the high rates of problem drinking among lawyers [3,7] and the well-established connection between substance misuse and suicide generally [77]. Future research should continue to examine the relationship between alcohol use and suicidal ideation in this population.

#### **6. Conclusions**

Efforts are underway within the legal profession to improve mental health, reduce the stigma associated with mental health disorders, and increase the overall wellbeing of lawyers. To support and inform those efforts, an enhanced empirical understanding of the profession's unique mental health risks is essential, including a better understanding of why lawyers are much more likely than the average person to experience suicidal thoughts. This research has begun to answer that question. To summarize, our findings suggest the profile of a lawyer with the highest risk for suicide is a lonely or socially isolated male with a high level of unmanageable stress, who is overly committed to their work, and may have a history of mental health problems. The heightened risk of suicidal ideation extends well beyond this specific profile, however, thereby necessitating a sustained focus on the factors we identified as predictive of that risk. Overall, these findings underscore the need for interventions to address work-related stress and loneliness in the legal profession. This may include providing education, resources, and support for lawyers to better manage their workload, modifying work demands and expectations, and promoting a culture of openness and support within law firms. Additionally, targeting interventions towards male lawyers may be particularly important given their higher risk of suicidal ideation. Further research is needed to continue exploring the dynamics of the relationship between work overcommitment, loneliness, perceived stress, and suicidal ideation in this population.

**Supplementary Materials:** The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare11040536/s1, Table S1: Predictors of PHQ-9 suicidal ideation among lawyers controlling for perceived influence of COVID-19 on PHQ-9 depression symptoms (N = 1962).

**Author Contributions:** Conceptualization, J.J.A. and P.R.K.; methodology, J.J.A.; software, J.J.A. and N.D.; validation, J.J.A. and N.D.; formal analysis, J.J.A.; investigation, J.J.A. and P.R.K.; resources, J.J.A. and P.R.K.; data curation, J.J.A. and N.D.; writing—original draft preparation, J.J.A., H.M.T. and P.R.K.; writing—review and editing, J.J.A., P.R.K. and M.R.K.; visualization, J.J.A. and M.R.K.; supervision, J.J.A. and P.R.K.; project administration, J.J.A. and P.R.K.; funding acquisition, J.J.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by NIAAA, grant number K01AA024805.

**Institutional Review Board Statement:** The study design and protocol were reviewed by the University of Minnesota Institutional Review Board and deemed exempt from approval. An Exemption Determination was issued on 20 March 2020.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Data cannot be shared publicly because they involve human research participants and contain potentially sensitive information related to mental health and substance use. Researchers who meet the criteria for access to confidential data may request to access the data by contacting the corresponding author and completing a University of Minnesota Data Use Agreement.

**Acknowledgments:** The authors would like to thank the California Lawyers Association and D.C. Bar for their essential support of and commitment to this work.

**Conflicts of Interest:** The authors declare no conflict of interest.
