Abstract
Objectives:
Healthcare workers (HCWs) face heightened suicide risk due to occupational stressors and other proximal and distal factors. To our knowledge, this study is the first study in Lebanon and among the first globally to examine the association between childhood adversities and suicidality among HCWs within overlapping national crises.
Methods:
We conducted a cross-sectional analysis of a cohort study among 390 HCWs in Lebanon. Using an online survey, data included sociodemographics, Beirut port blast, adulthood trauma, economic collapse, COVID-19, network/support, childhood adversities, mental health (PHQ-9/PCL-5), substance use, prior health and suicidality. Analyses in Stata used bivariate and stepwise logistic regressions to determine parsimonious predictors of suicidality in past-two-week and lifetime suicidality.
Results:
Childhood emotional neglect and depression emerged significantly predicted suicidality in the past-two-weeks. Younger age, PTSD due to childhood trauma, PTSD related to a loved one’s illness and depression were significantly associated with lifetime suicidality. Contrary to previous findings, COVID-19 stressors and financial difficulties were not retained in the final model.
Conclusion:
HCWs suicidality is associated with early-life adversities and trauma. Findings highlight the need for targeted interventions.
Introduction
“We define suicide as the act of intentionally ending one’s own life” [1]. As explained by Nock et al. [1], suicidal behaviors, described as non-fatal, are a group of three specific classifications: suicidal ideations; ideas to deliberately terminate one’s own life, suicidal planning; model of terminating one’s own life and suicidal attempt; actively participating in behaviors aiming to end one’s life without culminating in death.
Suicide remains under-researched in the 22 Arab World countries [2]. Large-scale studies show relatively low suicide rates, with the Eastern Mediterranean region reporting 6.4 per 100,000, below the global average of 9.0 per 100,000 [3]. In Lebanon, the age-standardized suicide rate in 2019 was 2.8 per 100,000.
Lebanon’s suicide data is primarily derived from the Internal Security Forces (ISF), which is the only official source on this issue [4]. Recent ISF data shows a 21.7% increase in suicide-related deaths in 2023 compared to 2022, and a 46% increase compared to 2021. These figures are nearing the levels recorded in 2019, which had the highest suicide rates of the past decade in Lebanon.
The rise in suicide cases may reflect actual increases or improved reporting mechanisms, but cultural stigma and underreporting obscure the true extent. Suicide remains a deep-seated taboo in Lebanon, affecting both the general population and healthcare workers (HCWs).
Suicidality among HCWs is influenced by several key factors [5]. First, stigma surrounding mental health in the healthcare profession often discourages workers from seeking help, as they fear judgment, loss of credibility, or professional repercussions. In particular, characteristics like perfectionism, though often valued in the workplace, may intensify suicidality [6]. Moreover, access to mental health resources is limited due to logistical challenges, including long wait times, improper mental health coverage, and heavy work schedules. Confidentiality concerns also play a significant role. Additionally, the high-stress nature of healthcare work—caring for critically ill patients, handling heavy workloads, delivering difficult news, and coping with death and suffering—contributes to chronic stress and emotional exhaustion [7]. HCWs' access to lethal means, such as medications, increases the risk of fatal suicide attempts [8]. Ethical dilemmas and moral injury also play a critical role in the mental health challenges faced by HCWs [9]. Moral injury refers to distress experienced when actions, or inactions, contradict one’s ethical or moral beliefs. This can arise in situations such as making life-altering decisions about allocating limited resources, like ventilators. While moral injury is not classified as a mental illness, its effects—such as negative self-perception, guilt, and shame—can lead to mental health issues like depression and suicidality.
In recent years, growing global attention has highlighted the mental health challenges faced by HCWs. Research has since focused on identifying risk and protective factors influencing suicidality in this group.
Major factors associated with increased suicidality among HCWs include various demographic, occupational, psychological, and social factors. Younger age [10–17], living alone [10, 18], a history of mental disorders [11, 16, 19], prior suicide attempts [10, 13, 20–24], working excessive hours [25–28] personal and loved ones physical health issues [10, 19, 29–31], poorer subjective health [10, 20, 23, 24, 32], change in vitamin D levels [33], personal and family problems [30, 34], exposure to sexual abuse [35], harassment [35, 36], or domestic violence [35], conflicts at work [30], financial stress [10, 19, 21], low organizational justice [30], and workplace discrimination [37–39], as well as not feeling support from superiors [11] are all associated with increased suicide risk. Poor sleep quality [10, 12, 16, 20, 23, 24, 40], frequent nightmares [10, 20, 23, 24, 32], workplace violence [41], and a perceived lack of control over working conditions — role conflict and degrading work experiences [42] — also contribute to increased odds. Additionally, suicidality was relatively high for participants characterized by several COVID-19-related factors, such as fear of the virus [43], lack of confidence in overcoming COVID-19 [15], COVID-19 infection in the community [15], perceived lack of institutional preparedness [19], reports of unreasonable demands and complaints from patients or their families [44], willingness to attend gatherings [15], need for psychological assistance before the outbreak or during the epidemic remission period [15, 29], not owning enough equipment to manage patients [45, 46], having changed to a specific COVID-19-related work location [11, 46, 47], or having an infected friend or family member [10, 19, 23, 29]. Psychological distress and poor mental health [10, 18, 19, 35, 48], including depression [10, 20, 29, 32, 48–52], anxiety [10, 11, 18, 20, 29, 48–51, 53, 54], post-traumatic stress disorder (PTSD) [10, 55], burnout [10, 12, 13, 45, 56, 57], exhaustion [58], severe general distress [14], and psychotropic drug use [21, 55] further heightens the likelihood of suicidality.
Several protective factors have been identified also. Having strong social support from family, friends, or colleagues [15, 16, 23, 29, 30, 42, 59], a high monthly income [10, 19, 21], confidence in standard precautions [14], and overall life satisfaction [60] are associated with a lower likelihood of suicidality.
Nonetheless, several factors yielded inconsistent results including gender, having children, having been isolated or quarantined due to COVID, having direct contact with people infected with COVID-19, seniority in the job, being married, substance use, smoking, education level, COVID‐19 infection history, history of psychiatric service contact [10, 11, 13–16, 18, 19, 21, 25–27, 29, 31, 32, 34, 35, 40, 45, 47–50, 54, 58, 59, 61–70].
While numerous studies have identified various risk and protective factors for suicidality among HCWs, many of these factors exhibit inconsistencies, and remain underexplored in the global literature. To address these gaps, to the best of our knowledge, this is the first study of its kind in Lebanon and among the first internationally to examine: 1) all types of suicidalities, 2) both clinical and non-clinical healthcare professionals, 3) two-time dimensions of suicidality (past 2 weeks and lifetime), and incorporates data on childhood and life adversities in relation to suicidality among HCWs in our context and worldwide. Additionally, it examines the impact of three major stressors—the COVID-19 pandemic (placed an unprecedented burden on the healthcare system, straining resources and exposing HCWs to sustained physical and psychological stress), the financial meltdown (the Lebanese currency was depreciating drastically, losing 98% of its value by 2022), and the Beirut Port blast of August 4, 2020 (resulted in substantial casualties, injuries, and destruction; was categorized as the largest non-nuclear explosion in modern history, resulting in over 200 fatalities, 6,000 injuries, and the displacement of 300,000 individuals [71]).
Methods
Study Design and Participants
The study population included health workers employed at Saint George Hospital University Medical Center (SGHUMC) which is located near the port, was extensively damaged and became a critical site for both victims and responders. The population included clinical, administrative, and supportive roles. All participants were aged 18 years or older [72].
The dataset used in this study is a cross-sectional analysis of the third wave of a large cohort research project where data was collected across multiple waves [73]. The first wave, conducted 9–15 days post-blast, was initiated during a mandatory COVID-19 testing campaign for hospital staff [74]. Data were collected face-to-face using self-administered questionnaires at the testing site. Waves 2, 3, and 4 of data collection occurred at 21–27 days, 6–7 months, and 2–2.5 years post-blast, respectively. These waves utilized an online platform to distribute surveys via email, SMS, WhatsApp, and QR-coded letters [72]. Waves 1 and 2 focused primarily on the Beirut port blast and collected data on acute stress disorder symptoms only. In contrast, wave 3 included additional mental health screening tools and a broader range of variables relevant to the present analysis. Of the 1927 HCWs who participated in wave 1, 808 participated in wave 3 (response rate = 41.8%) [72]. For the present analysis, only participants from wave 3 with complete data on all key variables were included, resulting in a final sample of 390 participants.
Instruments
Sociodemographic
Participants provided sociodemographic details, including age, gender, education, household composition, and profession (clinical vs. non-clinical).
Beirut Blast
Exposure to the Beirut Port Blast was assessed using a 9-item inventory capturing: location during the blast, personal injury, difficulty accessing medical care, injury or death of loved ones, damage to home, participation in rescue efforts, and seeing mutilated or dead bodies. Each exposure was assigned a weight (0–100) by an expert panel; the median weight per item was used to calculate a cumulative weighted exposure score. Full methodology was published elsewhere [74].
Previous Trauma Exposure and Reaction
Participants reported prior trauma exposure, including major accidents, life-threatening illness (self or loved ones), deaths of loved ones, and exposure to war or armed conflict. Childhood trauma items included physical abuse, emotional neglect, and sexual abuse. All responses were binary (Yes/No). PTSD-like reactions (lasting ≥1 month and causing distress or impairment) were also assessed and coded dichotomously.
Economic Situation
Financial strain was assessed with questions on changes in financial stability, lifestyle (basic/leisure), and household contributors over the previous year. Responses were categorized as “No change” and “Yes change.”
COVID-19 Exposure Score
A composite COVID-19 exposure score captured weighted pandemic-related experiences and concerns, including: violence due to being a healthcare worker (Yes/No), proximity to COVID-19 patients (Yes/No), adequacy of Personal Protective Equipment (PPE; Yes/No), death of a loved one (Yes/No), isolation (Yes/No), patient deaths, stigma (Yes/No), triage decisions (Yes/No), fear of infection or transmission (Yes/No), trust in institutions (5-point Likert scale: 1 = not at all to 5 = extremely), and training adequacy (Yes/No). Weights were based on expert-derived importance ratings.
COVID-19 Workplace
Participants indicated whether they had been reassigned to new teams or duties since the pandemic began (Yes/No).
Network and Support
Network and support were assessed with two 4-point Likert-scale items evaluating perceived emotional and practical support from colleagues and loved ones (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). In addition, participants indicated whether they felt a need for psychological support related to the COVID-19 pandemic, financial situation, or the Beirut explosion, with responses categorized as Yes/No.
Mental Health Disorders
PTSD symptoms were measured using the validated Arabic version of the PTSD Checklist for DSM-5 (PCL-5), with items rated on a 4-point Likert scale [75, 76]. A score of ≥2 considered symptom endorsement. Diagnosis followed DSM-5 criteria: at least one B item, one C item, two D items, and two E items. In this study, the scale is reliable with high internal consistency (α = 0.92).
Depressive symptoms over the past 2 weeks were assessed with the Arabic Patient Health Questionnaire-9 (PHQ-9) which has been rigorously validated in Lebanon across various population and demonstrated strong psychometric properties, confirming its utility to screen for depression in our context [77, 78]. Items were scored 0–3, yielding a total score (0–27). A cut-off of ≥10 indicated probable depression (sensitivity = 0.85; specificity = 0.89). Internal consistency was good (α = 0.89).
Substance Use
Substance use was assessed with items addressing changes in the use of tobacco (cigarettes, chewing tobacco, cigars) and alcoholic beverages (beer, wine, liquor) during the pandemic. Responses were categorized as: no use, decreased use, same use, or increased use since the pandemic.
Prior Health
Participants reported any chronic physical conditions (Yes/No) or pre-pandemic mental health diagnoses (Yes/No).
Suicide (Outcome)
The study’s primary outcome was suicide-related behaviors, assessed across two-time frames: the past 2 weeks and lifetime. Questions focused on four domains: wishing for death, suicidal thoughts, planning methods, and suicide attempts. To create a composite variable for analysis, a response of “yes” to any of the domains was categorized as a positive indication of suicide-related behavior. This composite variable, termed “any suicidality,” was generated separately for the past 2 weeks and lifetime experiences, enabling an assessment of both acute and historical suicide risk. Validated suicidality instruments were not included in the parent cohort due to survey length and feasibility constraints. Instead, these ad hoc items were selected to capture the core domains of suicidality while minimizing participant burden.
Statistical Analysis
In this study, missing data were addressed using complete case analysis (CCA), whereby only participants with no missing values on any of the variables included in the analysis were retained. CCA was chosen for its straightforward implementation as it does not involve complex imputation methods that could introduce bias if the assumptions of missingness mechanisms are violated [79].
The prevalence of suicide-related behaviors was calculated for both the past 2 weeks and lifetime (ever) experiences. For each domain—wish, thought, plan, and attempt—the frequency (N) and percentage (%) were reported. Additionally, the same measures were reported for the composite variable, “any suicidality,” which combined a positive response to any of the four domains.
Descriptive statistics were used to summarize all variables. For continuous variables, the mean and standard deviation (SD) were reported, while for categorical variables, frequency (N) and percentage (%) were presented.
To examine associations between suicidality (in the past 2 weeks and over the lifetime) and individual, trauma-related, and contextual predictors, bivariate logistic regression analyses were conducted. The predictors included sociodemographic characteristics, Beirut Blast exposure, previous trauma exposure and reactions, economic situation, COVID-19-related factors, network and social support, mental health disorders, substance use, and prior health conditions. For each analysis, unadjusted odds ratios (ORs) and p-values were reported.
Finally, a stepwise logistic regression analyses were conducted for “any suicidality” in the past 2 weeks and lifetime to identify the most parsimonious model given the number of predictors relative to our sample size. We acknowledge, however, that stepwise procedures have limitations, including overreliance on statistical criteria; nonetheless, all predictors in the initial models were selected based on a literature review informed by theory. Variables with a p-value <0.05 in the bivariate analysis were included in the multivariable model. The final models retained only variables that remained significant at this threshold, providing adjusted ORs for the key predictors of suicide-related behaviors.
Results
Descriptive Statistics
The study population was predominantly female, well-educated, and engaged in clinical professions, with a mean age of 37 years (SD = 12.32) (Supplementary Table S1).
Exposure to trauma was diverse, reflecting Lebanon’s history of conflict and recent catastrophic events.
The Beirut Blast was a major exposure (mean = 167.15, SD = 130.52), with participants reporting a wide range of severity scores (Supplementary Table S1).
Beyond this event, participants reported varied trauma histories, including major accidents (7.84%, n = 28), life-threatening illnesses (5.04%, n = 18: personal and 15.69%, n = 56: loved one), and the loss of loved ones (33.89%, n = 121) (Supplementary Table S1). A history of war-related exposure was common, with more than two-thirds of participants having lived through armed conflicts or explosions (Supplementary Table S1). Childhood adversity was also reported, with experiences ranging from physical abuse (17.37%, n = 62) and emotional neglect (14.85%, n = 53) to sexual abuse (5.32%, n = 19) (Supplementary Table S1). The psychological burden of these experiences was evident in PTSD symptoms, which varied based on the nature of the trauma. Financial strain was common as well.
Despite these challenges, many participants reported strong social support networks, both in the workplace (79.83%, n = 285) and within their personal lives (93.28%, n = 333) (Supplementary Table S1). Mental health screening revealed notable rates of PTSD (19.89%, n = 71) and depression (12.04%, n = 43) among participants (Supplementary Table S1). Changes in substance use patterns were notable, with increases in tobacco (12.32%, n = 44) and alcohol (8.96%, n = 32) consumption reported post pandemic (Supplementary Table S1) Detailed descriptive statistics are presented in Supplementary Table S1.
Bivariate Analysis
Statistical results for all analyses below are presented in Supplementary Material S1; Supplementary Tables S2,S3.
Age was significantly associated with suicide-related behaviors, with younger individuals exhibiting higher odds of both past 2 weeks (OR = 0.95, 95% CI = 0.91–0.99, p = 0.019) (Supplementary Table S2) and lifetime (OR = 0.91, 95% CI = 0.87–0.95, p < 0.001) suicide-related behaviors (Supplementary Table S3).
Certain types of trauma exposure were significantly associated with suicide-related behaviors. In the past 2 weeks, individuals who had experienced a major accident (OR = 3.36, 95% CI = 1.15–9.77, p = 0.026) or childhood emotional neglect (OR = 3.00, 95% CI = 1.22–7.36, p = 0.016) exhibited higher odds of suicide-related behaviors (Supplementary Table S2). Childhood physical abuse (OR = 2.42, 95% CI = 0.995–5.90, p = 0.051) approached significance (Supplementary Table S2).
Childhood emotional neglect (OR = 3.16, 95% CI = 1.55–6.46, p = 0.002), childhood physical abuse (OR = 3.19, 95% CI = 1.61–6.33, p = 0.001), and childhood sexual abuse (OR = 4.61, 95% CI = 1.71–12.41, p = 0.003) were significantly associated with an increased likelihood of reporting lifetime suicidality (Supplementary Table S3). PTSD symptoms due to childhood trauma exhibited a particularly strong association in lifetime suicide-related behaviors (OR = 38.75, 95% CI = 8.06–186.36, p < 0.001) (Supplementary Table S3). The death of a loved one not related to the Beirut Blast (OR = 2.06, 95% CI = 1.09–3.87, p = 0.025), major accident (OR = 2.55, 95% CI = 1.02–6.40, p = 0.046) and life-threatening physical illness of a loved one (OR = 2.54, 95% CI = 1.24–5.22, p = 0.011) were also significant, while life-threatening personal physical illness (OR = 2.88, 95% CI = 0.97–8.49 p = 0.056) approached significance (Supplementary Table S3). For PTSD symptoms resulting from traumatic events, only PTSD secondary to a loved one’s life-threatening physical illness (OR = 7.14, 95% CI = 2.88–17.73, p < 0.001) and PTSD secondary to death of a loved one (OR = 2.35, 95% CI = 1.03–5.34, p = 0.042) were significant (Supplementary Table S3).
Workplace reassignment during the pandemic was significantly linked to lifetime suicide-related behaviors (OR = 3.10, 95% CI = 1.59–6.06, p = 0.001) (Supplementary Table S3).
Individuals who needed psychological support due to the pandemic (OR = 2.48, 95% CI = 1.08–5.67, p = 0.032) or financial difficulties (OR = 2.32, 95% CI = 1.01–5.39, p = 0.049) had significantly higher odds of suicide-related behaviors in the past 2 weeks (Supplementary Table S2). For lifetime suicide-related behaviors, needing psychological support due to the pandemic (OR = 2.44, 95% CI = 1.27–4.65, p = 0.007) and the Beirut explosions (OR = 2.70, 95% CI = 1.43–5.10, p = 0.002) were significantly associated with increased odds (Supplementary Table S3).
Mental health showed a differential impact across both timeframes. In the past 2 weeks and over the lifetime, depression was significantly associated with higher odds of suicide-related behaviors (OR = 8.96, 95% CI = 3.76–21.34, p < 0.001; Supplementary Table S2) (OR = 5.07, 95% CI = 2.44–10.54, p < 0.001; Supplementary Table S3), while PTSD was not (OR = 1.30, 95% CI = 0.50–3.38, p = 0.594; Supplementary Table S2) (OR = 0.71, 95% CI = 0.30–1.67, p = 0.438; Supplementary Table S3).
Mental health diagnosis prior to the pandemic was significantly associated with suicide-related behaviors, both in the past 2-week (OR = 2.94, 95% CI = 1.04–8.32, p = 0.042; Supplementary Table S2) and lifetime (OR = 4.21, 95% CI = 1.69–10.46, p = 0.002; Supplementary Table S3). Increased tobacco and alcohol use since the pandemic was significantly associated with lifetime suicide-related behaviors (OR = 4.87, 95% CI = 2.27–10.43, p < 0.001), (OR = 3.52, 95% CI = 1.40–8.83, p = 0.007) (Supplementary Table S3). For further information, see Supplementary Tables S2,S3 in Supplementary Material S1.
Multivariable Analysis
In the Multivariable analysis using stepwise regression, different factors were retained as significant predictors of suicide-related behaviors for the past 2 weeks (Table 1) and lifetime (Table 2). Childhood emotional neglect (OR = 2.78, 95% CI = 1.06–7.26, p = 0.037) and depression (OR = 8.66, 95% CI = 3.59–20.87, p < 0.001) were significant predictors of suicidality in the past 2 weeks (Table 1). Younger age (OR = 0.91, 95% CI = 0.87–0.96, p < 0.001), PTSD symptoms resulting from childhood adversity (OR = 16.88, 95% CI = 3.16–90.23, p = 0.001) and from a life-threatening physical illness of a loved one (OR = 10.96, 95% CI = 3.27–36.75, p < 0.001) were associated with higher likelihood of reporting lifetime suicidality (Table 2). Additionally, depression remained a strong predictor (OR = 3.72, 95% CI = 1.61–8.58, p = 0.002) of lifetime suicidality as well (Table 2). These findings are also illustrated in Figure 1, which shows the predictors retained as significant in the stepwise models for past 2 weeks and lifetime suicidality.
TABLE 1
| Variables | Stepwise logistic regression | |||
|---|---|---|---|---|
| OR | p-value | 95% CI lower | 95% CI upper | |
| Childhood neglect | ||||
| No | Ref | |||
| Yes | 2.78 | 0.037* | 1.06 | 7.26 |
| Depression | ||||
| No | Ref | |||
| Yes | 8.66 | <0.001* | 3.59 | 20.87 |
Stepwise multivariable logistic regression of suicide in the past two weeks (Lebanon, 2020-2023).
OR, odds ratio; CI, confidence interval Ref = reference category.
*p ≤ 0.05.
TABLE 2
| Variables | Stepwise logistic regression | |||
|---|---|---|---|---|
| OR | p-value | 95% CI lower | 95% CI upper | |
| Age^ | 0.91 | <0.001* | 0.87 | 0.96 |
| PTSD symptoms secondary to childhood trauma | ||||
| No | Ref | |||
| Yes | 16.88 | 0.001* | 3.16 | 90.23 |
| PTSD symptoms secondary to a loved one’s life-threatening physical illness | ||||
| No | Ref | |||
| Yes | 10.96 | <0.001* | 3.27 | 36.75 |
| Depression | ||||
| No | Ref | |||
| Yes | 3.72 | 0.002* | 1.61 | 8.58 |
Stepwise multivariable logistic regression of lifetime suicide (Lebanon, 2020-2023).
OR, odds ratio; CI, confidence interval; Ref, reference category.
*p ≤ 0.05.
^continuous variable.
FIGURE 1
Pyramid of predictors of suicide risk: multivariable stepwise logistic regression (past 2 Weeks vs. lifetime) (Lebanon, 2020-2023).
Discussion
The mental health of HCWs has received increasing attention during the COVID-19 pandemic, particularly in relation to suicide risk. However, stressors do not occur in isolation; individuals are embedded in complex contexts shaped by both proximal and distal stressors. Understanding suicide risk among HCWs therefore requires a comprehensive examination of these cumulative and interacting stressors. To the best of our knowledge, this study is the first of its kind in Lebanon and among the first internationally to examine suicide risk among HCWs amidst overlapping collective stressors such as the Beirut port blast, the economic crisis, and the COVID-19 pandemic, while also accounting for childhood and adulthood adversities.
Previous research has predominantly focused on COVID-19-specific stressors, with limited attention to personal and family adulthood adversities [30, 34] and almost none on childhood adversities. Our study addresses this gap by incorporating the extensive literature linking childhood adversity to suicide risk in general populations [80–83]. Research has shown that physical and sexual abuse increases suicidality [84–87], although some studies found no association [88–90], likely due to sample variations, low prevalence or early onset of suicidal behavior [91]. In our study, emotional neglect emerged as a significant childhood adversity predictor alongside PTSD secondary to childhood adversities. This aligns with literature identifying emotional neglect as a powerful risk factor [82, 92, 93], potentially due to its lasting impact on emotional development and self-perception [80].
Although COVID-19-related stressors have been associated with suicide risk in prior studies, they were not retained in our final model. This may suggest that the impact of COVID-19 on suicidality operates indirectly, possibly through their association with depression and PTSD, which emerged as stronger predictors. It may also reflect the greater salience of broader stressors collected through our comprehensive consideration of contextual factors such as the economic crisis and cumulative adversities, which could overshadow the independent association of pandemic-related stressors when considered simultaneously. However, at the bivariate level, several factors such as exposure to COVID-19 cases, patient death, tobacco and alcohol use, stigma and workplace distrust, were significantly associated with suicide risk, aligning with previous studies [15, 19, 62] (Supplementary Material S1, Supplementary Table S4).
Our study also explored subjective financial strain. Rather than relying solely on income, we assessed participants’ perceptions of their financial situation to better reflect individual experience. This is an important departure from conventional approaches, as financial distress is influenced not just by income but also by expectations and obligations. Although subjective financial strain did not remain significant in our final model, this result reinforces the complexity of financial stress and highlights the need for more nuanced assessments in future research.
The meta-analysis spanning 50 years found minimal evidence supporting specific protective factors against suicide, as these factors are rarely examined and generally exhibit weak associations [83]. In our study, protective factors were not retained in the final model. We attribute this to the ad-hoc nature of our assessment, and suggest that 11future research look at various aspects of social networks and support, including tangible, emotional, and affectionate support.
Adulthood adversities such as major accidents, physical illness of a loved one, and the death of a loved one were associated with suicide risk at the bivariate level. At multi-level, only PTSD related to a loved one’s physical illness remained significant. This suggests that although adulthood adversities are impactful, their effects may be more situational and transient compared to the long-term imprint of childhood trauma.
Depression, as expected, was a strong predictor of suicidality, in line with prior evidence [10, 20, 29, 32, 48–52]. Younger age also emerged as an independent predictor of suicide-related behaviors in our sample. This finding is consistent with prior research highlighting increased vulnerability among early-career healthcare workers [10–17], who often face high workloads, limited professional autonomy, and job insecurity. These stressors may heighten susceptibility to psychological distress and suicidality, particularly in the context of Lebanon’s overlapping crises.
A key methodological strength of this study was the use of weighted scores for stressors, enabling a more refined analysis than simple stressor counts. This approach mitigates the oversimplification that arises from merely counting stressors and provides a more nuanced understanding of their impact.
Additionally, our inclusion of multiple layers of adversity (childhood trauma, adulthood events, and collective crises) provided a rich framework for understanding suicide risk in this unique context. Additionally, rather than relying solely on objective indicators of financial hardship, our study emphasized the role of subjective financial strain, highlighting the importance of individual perception in financial stress assessments. Our study also examined individual responses to adversity by including PTSD symptoms, recognizing that the same event may elicit varied psychological impacts. The finding that PTSD related to both childhood adversity and a loved one’s illness were significant predictors highlights the importance of trauma responses over mere exposure.
Limitations
Despite its strengths, the study has several limitations. Self-reported data may be affected by recall bias or underreporting due to stigma or social desirability—especially for sensitive topics like childhood abuse and suicidal thoughts. Additionally, the cross-sectional nature of the analysis limits causal inference. Important variables such as burnout, marital status, substance use, and anxiety were not included, and PTSD was assessed through a single ad-hoc question, potentially underestimating its complexity. Suicide risk was also measured using ad-hoc items rather than standardized instruments, which may reduce reliability and comparability. Furthermore, our reliance on screening tools rather than clinical diagnoses introduces a risk of misclassification, although such tools are commonly used in population research. Moreover, as the study was monocentric in nature, findings may not be generalizable to all healthcare workers in Lebanon or the broader region. Lastly, sample attrition from 808 to 390 participants raises concerns about selection bias.
Conclusion
In conclusion, although this study relied on self-reported data, employed a cross-sectional design, did not include burnout, anxiety, marital status, and substance use as predictors, used ad-hoc questions rather than tools to assess suicidality, and was monocentric, it offers valuable insights into the multifaceted stressors that are associated with suicide risk among HCWs in Lebanon during the COVID-19 pandemic and concurrent national crises. Emotional neglect in childhood, depression, younger age and PTSD reactions to childhood and adulthood adversities were key predictors of suicide risk. Our findings emphasize the importance of adopting a life-course perspective when examining suicide risk, incorporating both early-life and recent adversities. Future prevention strategies should integrate trauma-informed care and targeted support for HCWs with a history of early adversity. Researchers should also prioritize validated tools and longitudinal designs to deepen understanding and guide effective interventions.
Statements
Ethics statement
The studies involving humans were approved by the Institutional Review Board (IRB) at Saint George Hospital University Medical Center (SGHUMC) which is registered with the U.S. Office of Human Research Protections (OHRP) in the Department of Health and Human Services. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
JA contributed to the conceptualization, data curation, formal analysis, investigation, methodology, software, supervision, validation, and led the writing of the original draft as well as the review and editing. M-LW, JA, and RO contributed to the writing of the original draft and participated in the review and editing process. EK contributed to the conceptualization, investigation, methodology, project administration, and resources, and also participated in the review and editing of the manuscript. All authors contributed to the article and approved the submitted version.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Conflict of interest
The authors declare that they do not have any conflicts of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.ssph-journal.org/articles/10.3389/ijph.2025.1608725/full#supplementary-material
References
1.
Nock MK Borges G Bromet EJ Cha CB Kessler RC Lee S . Suicide and Suicidal Behavior. Epidemiol Rev (2008) 30:133–54. 10.1093/epirev/mxn002
2.
Daouk S Awaad R Ahmed B Barakat S Muñoz RF Leykin Y . Common and Country-Specific Characteristics Associated with Suicidality in the Arab Region. J Clin Psychiatry (2020) 82:19m13199. 10.4088/JCP.19m13199
3.
World Health Organization. Suicide Worldwide in 2019 (2021). Available online at: https://www.who.int/publications/i/item/9789240026643 (Accessed April 20, 2025).
4.
Embrace. Lebanon's 2023 Suicide Rates: What Do This Year's Numbers Tell Us About Mental Health in the Country (2023). Available online at: https://www.embracelebanon.org/Media/publications/pdfs/dc722868-a519-4afb-89fc-31b2165c442d.pdf (Accessed April 20, 2025).
5.
Qattan Y Almarzooq H Khoj R Alzahrani A Alotibi B Areeshi W et al Suicide Among Healthcare Workers: Risk Factors, Prevention, and Challenges. J Healthc Sci (2024) 04:64–70. 10.52533/JOHS.2024.40108
6.
Dutheil F Aubert C Pereira B Dambrun M Moustafa F Mermillod M et al Suicide Among Physicians and Health-Care Workers: A Systematic Review and Meta-Analysis. PLoS One (2019) 14:e0226361. 10.1371/journal.pone.0226361
7.
Olfson M Cosgrove CM Wall MM Blanco C . Suicide Risks of Health Care Workers in the US. JAMA (2023) 330:1161–6. 10.1001/jama.2023.15787
8.
Jain L Sarfraz Z Karlapati S Kazmi S Nasir MJ Atiq N et al Suicide in Healthcare Workers: An Umbrella Review of Prevalence, Causes, and Preventive Strategies. J Prim Care Community Health (2024) 15:21501319241273242. 10.1177/21501319241273242
9.
Søvold LE Naslund JA Kousoulis AA Saxena S Qoronfleh MW Grobler C et al Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority. Front Public Health (2021) 9:679397. 10.3389/fpubh.2021.679397
10.
Bismark M Scurrah K Pascoe A Willis K Jain R Smallwood N . Thoughts of Suicide or Self-Harm Among Australian Healthcare Workers During the COVID-19 Pandemic. Aust N Z J Psychiatry (2022) 56:1555–65. 10.1177/00048674221075540
11.
Mortier P Vilagut G Ferrer M Serra C Molina JD López-Fresneña N et al Thirty-Day Suicidal Thoughts and Behaviors Among Hospital Workers During the First Wave of the Spain COVID-19 Outbreak. Depress Anxiety (2021) 38:528–44. 10.1002/da.23129
12.
Martínez-Arriaga RJ Dominguez-Rodriguez A Herdoiza-Arroyo PE Robles-Garcia R de la Rosa-Gómez A Figueroa González JA et al Suicide Risk and Associated Factors in Healthcare Workers Seeking Psychological Support During COVID-19: A Cross-Sectional Study. Psychol Health Med (2023) 28:3076–90. 10.1080/13548506.2023.2216469
13.
de la Vega Sánchez D Irigoyen-Otiñano M Carballo JJ Guija JA Giner L . Suicidal Thoughts and Burnout Among Physicians During the First Wave of the COVID-19 Pandemic in Spain. Psychiatry Res (2023) 321:115057. 10.1016/j.psychres.2023.115057
14.
Ide K Asami T Suda A Yoshimi A Fujita J Shiraishi Y et al The Psychological Distress and Suicide-Related Ideation in Hospital Workers During the COVID-19 Pandemic: Second Results From Repeated Cross-Sectional Surveys. PLoS One (2022) 17:e0277174. 10.1371/journal.pone.0277174
15.
Lixia W Xiaoming X Lei S Su H Wo W Xin F et al A Cross-Sectional Study of the Psychological Status of 33,706 Hospital Workers at the Late Stage of the COVID-19 Outbreak. J Affect Disord (2022) 297:156–68. 10.1016/j.jad.2021.10.013
16.
Ortiz-Calvo E Martínez-Alés G Mediavilla R González-Gómez E Fernández-Jiménez E Bravo-Ortiz MF et al The Role of Social Support and Resilience in the Mental Health Impact of the COVID-19 Pandemic Among Healthcare Workers in Spain. J Psychiatr Res (2022) 148:181–7. 10.1016/j.jpsychires.2021.12.030
17.
Sato H Maeda M Takebayashi Y Setou N Shimada J Kanari Y . Impact of Unexpected In-House Major COVID-19 Outbreaks on Depressive Symptoms Among Healthcare Workers: A Retrospective Multi-Institutional Study. Int J Environ Res Public Health (2023) 20:4718. 10.3390/ijerph20064718
18.
Alyahya KI Alrefaei RM Almadhyani LF AlQuwayz SS AlOmairini MI Alsayed FA et al The Prevalence and Correlation of Suicidal Ideation Among Nurses in King Saud University Medical City. Cureus (2023) 15:e44859. 10.7759/cureus.44859
19.
Mortier P Vilagut G Alayo I Ferrer M Amigo F Aragonès E et al Four-Month Incidence of Suicidal Thoughts and Behaviors Among Healthcare Workers After the First Wave of the Spain COVID-19 Pandemic. J Psychiatr Res (2022) 149:10–7. 10.1016/j.jpsychires.2022.02.009
20.
Que JY Shi L Yan W Chen SJ Wu P Sun SW et al Nightmares Mediate the Association Between Traumatic Event Exposure and Suicidal Ideation in Frontline Medical Workers Exposed to COVID-19. J Affect Disord (2022) 304:12–9. 10.1016/j.jad.2022.02.033
21.
Oliveira MM Treichel C Bakolis I Alves PF Coimbra VCC Cavada GP et al Mental Health of Nursing Professionals During the COVID-19 Pandemic: A Cross-Sectional Study. Rev Saude Publica (2022) 56:8. 10.11606/s1518-8787.2022056004122
22.
Freire FO Marcon SR Espinosa MM Santos H Kogien M Lima NVP et al Factors Associated with Suicide Risk Among Nurses and Physicians: A Cross-Section Study. Rev Bras Enferm (2020) 73:e20200352. 10.1590/0034-7167-2020-0352
23.
Hong S Ai M Xu X Wang W Chen J Zhang Q et al Immediate Psychological Impact on Nurses Working at 42 Government-Designated Hospitals During COVID-19 Outbreak in China: A Cross-Sectional Study. Nurs Outlook (2021) 69:6–12. 10.1016/j.outlook.2020.07.007
24.
Xiaoming X Ming A Su H Wo W Jianmei C Qi Z et al The Psychological Status of 8817 Hospital Workers During COVID-19 Epidemic: A Cross-Sectional Study in Chongqing. J Affect Disord (2020) 276:555–61. 10.1016/j.jad.2020.07.092
25.
Ishikawa M . Long Working Hours, Depression and Suicidality Among OB/GYNs in Japan. Occup Med (Lond) (2022) 72:200–6. 10.1093/occmed/kqab191
26.
Petrie K Crawford J LaMontagne AD Milner A Dean J Veness BG et al Working Hours, Common Mental Disorder and Suicidal Ideation Among Junior Doctors in Australia: A Cross-Sectional Survey. BMJ Open (2020) 10:e033525. 10.1136/bmjopen-2019-033525
27.
Ishikawa M . Relationships Between Overwork, Burnout and Suicidal Ideation Among Resident Physicians in Hospitals in Japan with Medical Residency Programmes: A Nationwide Questionnaire-Based Survey. BMJ Open (2022) 12:e056283. 10.1136/bmjopen-2021-056283
28.
Okawara M Ishimaru T Yoshikawa T Kido M Nakashima Y Nakayasu A et al Working Hours, Side Work, and Depressive Symptoms in Physicians: A Nationwide Cross-Sectional Study in Japan. J Occup Health (2022) 64:e12377. 10.1002/1348-9585.12377
29.
Xu X Wang W Chen J Ai M Shi L Wang L et al Suicidal and Self-Harm Ideation Among Chinese Hospital Staff During the COVID-19 Pandemic: Prevalence and Correlates. Psychiatry Res (2021) 296:113654. 10.1016/j.psychres.2020.113654
30.
Lindfors PM Meretoja OA Luukkonen RA Elovainio MJ Leino TJ . Suicidality Among Finnish Anaesthesiologists. Acta Anaesthesiol Scand (2009) 53:1027–35. 10.1111/j.1399-6576.2009.02014.x
31.
Ji YD Robertson FC Patel NA Peacock ZS Resnick CM . Assessment of Risk Factors for Suicide Among US Health Care Professionals. JAMA Surg (2020) 155:713–21. 10.1001/jamasurg.2020.1338
32.
Höller I Forkmann T . Ambivalent Heroism? - Psychological Burden and Suicidal Ideation Among Nurses During the COVID-19 Pandemic. Nurs Open (2022) 9:785–800. 10.1002/nop2.1130
33.
Duru H . The Continuing Effect of COVID-19 Pandemic on Physical Well-Being and Mental Health of ICU Healthcare Workers in Turkey: A Single-Centre Cross-Sectional Later-Phase Study. J Intensive Care Med (2022) 37:1206–14. 10.1177/08850666211070740
34.
Hem E GrŁnvold NT Aasland OG Ekeberg O . The Prevalence of Suicidal Ideation and Suicidal Attempts Among Norwegian Physicians. Results From a Cross-Sectional Survey of a Nationwide Sample. Eur Psychiatry (2000) 15:183–9. 10.1016/s0924-9338(00)00227-3
35.
Frank E Dingle AD . Self-Reported Depression and Suicide Attempts Among U.S. Women Physicians. Am J Psychiatry (1999) 156:1887–94. 10.1176/ajp.156.12.1887
36.
Fridner A Belkic K Marini M Minucci D Pavan L Schenck-Gustafsson K . Survey on Recent Suicidal Ideation Among Female University Hospital Physicians in Sweden and Italy (The HOUPE Study): Cross-Sectional Associations With Work Stressors. Gend Med (2009) 6:314–28. 10.1016/j.genm.2009.04.006
37.
Campo-Arias A Jiménez-Villamizar MP Caballero-Domínguez CC . Healthcare Workers' Distress and Perceived Discrimination Related to COVID-19 in Colombia. Nurs Health Sci (2021) 23:763–7. 10.1111/nhs.12854
38.
Mediavilla R Fernández-Jiménez E Andreo J Morán-Sánchez I Muñoz-Sanjosé A Moreno-Küstner B et al Association Between Perceived Discrimination and Mental Health Outcomes Among Health Workers During the Initial COVID-19 Outbreak. Span J Psychiatry Ment Health (2023) 16:221–4. 10.1016/j.rpsm.2021.06.001
39.
Narita Z Okubo R Sasaki Y Takeda K Ohmagari N Yamaguchi K et al Association of COVID-19-related Discrimination with Subsequent Depression and Suicidal Ideation in Healthcare Workers. J Psychiatr Res (2023) 159:153–8. 10.1016/j.jpsychires.2023.01.025
40.
Ng APP Chin WY Wan EYF Chen J Lau CS . Prevalence of Depression and Suicide Ideation in Hong Kong Doctors: A Cross-Sectional Study. Sci Rep (2021) 11:19366. 10.1038/s41598-021-98668-4
41.
Tiesman HM Hendricks SA Wiegand DM Lopes-Cardozo B Rao CY Horter L et al Workplace Violence and the Mental Health of Public Health Workers During COVID-19. Am J Prev Med (2023) 64:315–25. 10.1016/j.amepre.2022.10.004
42.
Fridner A Belkić K Minucci D Pavan L Marini M Pingel B et al Work Environment and Recent Suicidal Thoughts Among Male University Hospital Physicians in Sweden and Italy: The Health and Organization Among University Hospital Physicians in Europe (HOUPE) Study. Gend Med (2011) 8:269–79. 10.1016/j.genm.2011.05.009
43.
Lin YH Chen JS Huang PC Lu MY Strong C Lin CY et al Factors Associated with Insomnia and Suicidal Thoughts Among Outpatients, Healthcare Workers, and the General Population in Taiwan During COVID-19 Pandemic: A Cross-Sectional Study. BMC Public Health (2022) 22:2135. 10.1186/s12889-022-14557-z
44.
Wada K Yoshikawa T Goto T Hirai A Matsushima E Nakashima Y et al Association of Depression and Suicidal Ideation with Unreasonable Patient Demands and Complaints Among Japanese Physicians: A National Cross-Sectional Survey. Int J Behav Med (2011) 18:384–90. 10.1007/s12529-010-9132-7
45.
Kabir H Chowdhury SR Roy AK Chowdhury SA Islam MN Chomon RJ et al Association of Workplace Bullying and Burnout with Nurses' Suicidal Ideation in Bangladesh. Sci Rep (2023) 13:14641. 10.1038/s41598-023-41594-4
46.
Mediavilla R Fernández-Jiménez E Martínez-Alés G Moreno-Küstner B Martínez-Morata I Jaramillo F et al Role of Access to Personal Protective Equipment, Treatment Prioritization Decisions, and Changes in Job Functions on Health Workers' Mental Health Outcomes During the Initial Outbreak of the COVID-19 Pandemic. J Affect Disord (2021) 295:405–9. 10.1016/j.jad.2021.08.059
47.
Fountoulakis KN Karakatsoulis GN Abraham S Adorjan K Ahmed HU Alarcón RD et al Results of the COVID-19 Mental Health International for the Health Professionals (COMET-HP) Study: Depression, Suicidal Tendencies and Conspiracism. Soc Psychiatry Psychiatr Epidemiol (2023) 58:1387–410. 10.1007/s00127-023-02438-8
48.
Al-Humadi S Bronson B Muhlrad S Paulus M Hong H Cáceda R . Depression, Suicidal Thoughts, and Burnout Among Physicians During the COVID-19 Pandemic: A Survey-Based Cross-Sectional Study. Acad Psychiatry (2021) 45:557–65. 10.1007/s40596-021-01490-3
49.
Salman M Mallhi TH Khan YH Mustafa ZU Shehzadi N Khan TM et al Suicidal Ideation amid COVID-19 Pandemic: A Cross-Sectional Study Among Healthcare Workers During the First Wave of COVID-19 in Pakistan. Disaster Med Public Health Prep (2022) 16:2243–4. 10.1017/dmp.2022.124
50.
Sahimi HMS Mohd Daud TI Chan LF Shah SA Rahman FHA Nik Jaafar NR . Depression and Suicidal Ideation in a Sample of Malaysian Healthcare Workers: A Preliminary Study During the COVID-19 Pandemic. Front Psychiatry (2021) 12:658174. 10.3389/fpsyt.2021.658174
51.
Parthasarathy R Ts J K T Murthy P . Mental Health Issues Among Health Care Workers During the COVID-19 Pandemic - A Study from India. Asian J Psychiatr (2021) 58:102626. 10.1016/j.ajp.2021.102626
52.
Alvarado R Ramírez J Lanio Í Cortés M Aguirre J Bedregal P et al Impact of COVID-19 Pandemic on the Mental Health of Healthcare Workers. Rev Med Chil (2021) 149:1205–14. 10.4067/s0034-98872021000801205
53.
Ariapooran S Ahadi B Khezeli M . Depression, Anxiety, and Suicidal Ideation in Nurses with and Without Symptoms of Secondary Traumatic Stress During the COVID-19 Outbreak. Arch Psychiatr Nurs (2022) 37:76–81. 10.1016/j.apnu.2021.05.005
54.
Abdelghani M Hassan MS Elgohary HM Fouad E . Exploring the Factors Associated with Coronaphobia Among Physicians During the COVID-19 Outbreak in Egypt. Egypt J Neurol Psychiatr Neurosurg (2021) 57:105. 10.1186/s41983-021-00357-6
55.
Bruffaerts R Voorspoels W Jansen L Kessler RC Mortier P Vilagut G et al Suicidality Among Healthcare Professionals During the First COVID19 Wave. J Affect Disord (2021) 283:66–70. 10.1016/j.jad.2021.01.013
56.
Menon NK Shanafelt TD Sinsky CA Linzer M Carlasare L Brady KJS et al Association of Physician Burnout with Suicidal Ideation and Medical Errors. JAMA Netw Open (2020) 3:e2028780. 10.1001/jamanetworkopen.2020.28780
57.
Chin WS Chen YC Ho JJ Cheng NY Wu HC Shiao JSC . Psychological Work Environment and Suicidal Ideation Among Nurses in Taiwan. J Nurs Scholarsh (2019) 51:106–13. 10.1111/jnu.12441
58.
Jesus A Pitacho L Moreira A . Burnout and Suicidal Behaviours in Health Professionals in Portugal: The Moderating Effect of Self-Esteem. Int J Environ Res Public Health (2023) 20:4325. 10.3390/ijerph20054325
59.
Nie G Du J Liu J Yuan L Ma Z . Job Stress and Suicidal Ideation Among Chinese Clinicians: The Moderating Role of Social Support. J Gen Psychol (2020) 147:109–22. 10.1080/00221309.2019.1640657
60.
Akram B Bibi B Ashfaq Ahmed M Kausar N . Work-Family Conflict and Suicidal Ideation Among Physicians of Pakistan: The Moderating Role of Perceived Life Satisfaction. Omega (Westport) (2022) 85:465–82. 10.1177/0030222820947246
61.
Stelnicki AM Jamshidi L Angehrn A Nicholas Carleton R . Suicidal Behaviors Among Nurses in Canada. Can J Nurs Res (2020) 52:226–36. 10.1177/0844562120934237
62.
Braquehais MD González-Irizar O Nieva G Mozo X Llavayol E Pujol T et al Assessing High Risk of Suicide Amongst Physicians and Nurses in Treatment. Psychiatry Res (2020) 291:113237. 10.1016/j.psychres.2020.113237
63.
Mamun MA Akter T Zohra F Sakib N Bhuiyan A Banik PC et al Prevalence and Risk Factors of COVID-19 Suicidal Behavior in Bangladeshi Population: Are Healthcare Professionals at Greater Risk? Heliyon (2020) 6:e05259. 10.1016/j.heliyon.2020.e05259
64.
Cai Q Feng H Huang J Wang M Wang Q Lu X et al The Mental Health of Frontline and Non-Frontline Medical Workers During the Coronavirus Disease 2019 (COVID-19) Outbreak in China: A Case-Control Study. J Affect Disord (2020) 275:210–5. 10.1016/j.jad.2020.06.031
65.
Majumder P Jeve Y Sales CP . Voices From the Frontline: The Psychological Impact and Coping Mechanisms Used by Healthcare Staff During COVID-19. Br J Healthc Manag (2021) 27:1–11. 10.12968/bjhc.2020.0168
66.
Bayazit H Ozel M Arac S Dulgeroglu-Bayazit D Joshi A . Posttraumatic Stress Disorder Among Health Care Workers During the COVID-19 Pandemic. J Psychiatr Pract (2022) 28:354–61. 10.1097/pra.0000000000000661
67.
Dyrbye LN West CP Satele D Boone S Tan L Sloan J et al Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population. Acad Med (2014) 89:443–51. 10.1097/acm.0000000000000134
68.
Hu YY Ellis RJ Hewitt DB Yang AD Cheung EO Moskowitz JT et al Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med (2019) 381:1741–52. 10.1056/NEJMsa1903759
69.
Loas G Lefebvre G Rotsaert M Englert Y . Relationships Between Anhedonia, Suicidal Ideation and Suicide Attempts in a Large Sample of Physicians. PLoS One (2018) 13:e0193619. 10.1371/journal.pone.0193619
70.
Hawton K Agerbo E Simkin S Platt B Mellanby RJ . Risk of Suicide in Medical and Related Occupational Groups: A National Study Based on Danish Case Population-Based Registers. J Affect Disord (2011) 134:320–6. 10.1016/j.jad.2011.05.044
71.
El Sayed MJ . Beirut Ammonium Nitrate Explosion: A Man-Made Disaster in Times of the COVID-19 Pandemic. Disaster Med Public Health Prep (2022) 16:1203–7. 10.1017/dmp.2020.451
72.
Karam EG Al Barathie J Dimassi H Mascayano F Slim A Karam A et al Unveiling the Neglected Role of the Intensity of Acute Stress Disorder in the Prediction of Full- and Sub-Threshold Posttraumatic Stress Disorder: Looking Beyond the Diagnosis. Soc Psychiatry Psychiatr Epidemiol (2024) 60:1125–33. 10.1007/s00127-024-02805-z
73.
Mascayano F van der Ven E Moro MF Schilling S Alarcón S Al Barathie J et al The Impact of the COVID-19 Pandemic on the Mental Health of Healthcare Workers: Study Protocol for the COVID-19 Health Care Workers (HEROES) Study. Soc Psychiatry Psychiatr Epidemiol (2022) 57:633–45. 10.1007/s00127-021-02211-9
74.
Karam E Saab D Al Barathie J Karam AN Karam G Bryant R . Predictors and Severity of Probable Acute Stress Disorder Following the Beirut Port Blast. Eur J Psychotraumatol (2022) 13:2040232. 10.1080/20008198.2022.2040232
75.
Alhalaiqa F Alfuqaha OA Masa'Deh R Khalifeh AH Alsaraireh M Manaa NS et al Psychometric Properties of the Posttraumatic Stress Disorder Checklist Among the Lebanese Population Exposed to the Beirut Explosion: A Cross-Sectional Study During the COVID-19 Pandemic. Behav Neurol (2023) 2023:9286562. 10.1155/2023/9286562
76.
Al Barathie J Karam EG . Exploratory Factor Analysis of Post Traumatic Stress Disorder Checklist for DSM-5: Investigating Post Traumatic Stress Disorder Interconnected Dynamics with Depression and Anxiety in the Aftermath of Multiple Collective Stressors. PLoS One (2025) 20:e0323422. 10.1371/journal.pone.0323422
77.
Sawaya H Atoui M Hamadeh A Zeinoun P Nahas Z . Adaptation and Initial Validation of the Patient Health Questionnaire - 9 (PHQ-9) and the Generalized Anxiety Disorder - 7 Questionnaire (GAD-7) in an Arabic Speaking Lebanese Psychiatric Outpatient Sample. Psychiatry Res (2016) 239:245–52. 10.1016/j.psychres.2016.03.030
78.
Summaka M Zein H Abbas LA Elias C Elias E Fares Y et al Validity and Reliability of the Arabic Patient Health Questionnaire-9 in Patients With Spinal Cord Injury in Lebanon. World Neurosurg (2019) 125:e1016–22. 10.1016/j.wneu.2019.01.234
79.
Hughes RA Heron J Sterne JAC Tilling K . Accounting for Missing Data in Statistical Analyses: Multiple Imputation Is Not Always the Answer. Int J Epidemiol (2019) 48:1294–304. 10.1093/ije/dyz032
80.
Angelakis I Gillespie EL Panagioti M . Childhood Maltreatment and Adult Suicidality: A Comprehensive Systematic Review With Meta-Analysis. Psychol Med (2019) 49:1057–78. 10.1017/s0033291718003823
81.
Liu RT Scopelliti KM Pittman SK Zamora AS . Childhood Maltreatment and Non-Suicidal Self-Injury: A Systematic Review and Meta-Analysis. Lancet Psychiatry (2018) 5:51–64. 10.1016/s2215-0366(17)30469-8
82.
Liu J Fang Y Gong J Cui X Meng T Xiao B et al Associations Between Suicidal Behavior and Childhood Abuse and Neglect: A Meta-Analysis. J Affect Disord (2017) 220:147–55. 10.1016/j.jad.2017.03.060
83.
Franklin JC Ribeiro JD Fox KR Bentley KH Kleiman EM Huang X et al Risk Factors for Suicidal Thoughts and Behaviors: A Meta-Analysis of 50 Years of Research. Psychol Bull (2017) 143:187–232. 10.1037/bul0000084
84.
Altwaijri Y Benjet C Al-Habeeb A Al-Subaie A Akkad M Alammar S et al Suicidal Thoughts and Behaviors in the Kingdom of Saudi Arabia. J Affect Disord (2024) 352:429–36. 10.1016/j.jad.2024.02.060
85.
Bruffaerts R Demyttenaere K Borges G Haro JM Chiu WT Hwang I et al Childhood Adversities as Risk Factors for Onset and Persistence of Suicidal Behaviour. Br J Psychiatry (2010) 197:20–7. 10.1192/bjp.bp.109.074716
86.
Bruwer B Govender R Bishop M Williams DR Stein DJ Seedat S . Association Between Childhood Adversities and long-term Suicidality Among South Africans From the Results of the South African Stress and Health Study: A Cross-Sectional Study. BMJ Open (2014) 4:e004644. 10.1136/bmjopen-2013-004644
87.
Coêlho BM Andrade LH Borges G Santana GL Viana MC Wang YP . Do Childhood Adversities Predict Suicidality? Findings From the General Population of the Metropolitan Area of São Paulo, Brazil. PLoS One (2016) 11:e0155639. 10.1371/journal.pone.0155639
88.
Navarro-Mateu F Salmerón D Vilagut G Husky M Ballesta M Chirlaque MD et al Childhood Adversities and Suicidal Behavior in the General Population. the cross-sectional PEGASUS-Murcia Project. Span J Psychiatry Ment Health (2024) 17:11–8. 10.1016/j.rpsm.2020.10.002
89.
Salokangas RKR Luutonen S Heinimaa M From T Hietala J . A Study on the Association of Psychiatric Diagnoses and Childhood Adversities with Suicide Risk. Nord J Psychiatry (2019) 73:125–31. 10.1080/08039488.2018.1493748
90.
Bernegger A Kienesberger K Carlberg L Swoboda P Ludwig B Koller R et al Influence of Sex on Suicidal Phenotypes in Affective Disorder Patients with Traumatic Childhood Experiences. PLoS One (2015) 10:e0137763. 10.1371/journal.pone.0137763
91.
Enns MW Cox BJ Afifi TO De Graaf R Ten Have M Sareen J . Childhood Adversities and Risk for Suicidal Ideation and Attempts: A Longitudinal Population-based Study. Psychol Med (2006) 36:1769–78. 10.1017/s0033291706008646
92.
Barbosa LP Quevedo L da Silva Gdel G Jansen K Pinheiro RT Branco J et al Childhood Trauma and Suicide Risk in a Sample of Young Individuals Aged 14-35 Years in Southern Brazil. Child Abuse Negl (2014) 38:1191–6. 10.1016/j.chiabu.2014.02.008
93.
Burns EE Jackson JL Harding HG . Child Maltreatment, Emotion Regulation, and Posttraumatic Stress: The Impact of Emotional Abuse. J Aggress Maltreat Trauma (2010) 19:801–19. 10.1080/10926771.2010.522947
Summary
Keywords
suicide, childhood adversities, Beirut blast, COVID-19, economic collapse, healthcare workers
Citation
Al Barathie J, Wakim M-L, Allabaky J, Osman R and Karam E (2025) Suicidality Among Healthcare Workers in Lebanon: Associations With Childhood Adversities Amid Recent Overlapping Crises. Int. J. Public Health 70:1608725. doi: 10.3389/ijph.2025.1608725
Received
21 May 2025
Accepted
24 September 2025
Published
13 October 2025
Volume
70 - 2025
Edited by
Bojana Knezevic, University Hospital Centre Zagreb, Croatia
Reviewed by
Iva Lončarić Kelečić, University Hospital Centre Zagreb, Croatia
Updates
Copyright
© 2025 Al Barathie, Wakim, Allabaky, Osman and Karam.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Elie Karam, egkaram@idraac.org
†These authors have contributed equally to this work
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.