An Evaluation of Suicidality and Its Predictors in Police Officers in Lagos, Nigeria

Background: The many dangers and stressors associated with police work often place police officers at a great risk of a variety of mental health morbidity, including suicidality. The causation of suicidality is multi-dimensional, however, there are insufficient studies which have examined the burden and risk factors of suicidality in Nigerian police officers. Objective: To determine the prevalence and predictors of suicidality among police officers in Lagos, Nigeria. Methods: This was a cross-sectional study of 600 police officers who were selected using a non-probability sampling method. Questionnaires used were: Suicide Behaviour Questionnaire-Revised (SBQ-R), State-Trait Anxiety Inventory (STAI), and a Socio-Demographic Questionnaire. Results: Prevalence of suicidality was 14%, and the predictors of suicidality were: state anxiety (p < 0.001), trait anxiety (p < 0.001), substance use (p = 0.03), being unmarried (p = 0.03), and female gender (p = 0.02). Conclusion: Suicidality is prevalent among Nigerian police officers, with a higher risk in those who are vulnerable. The creation of government policies and infrastructure which promote mental health in police officers is necessary.


Introduction
Suicidality is the risk of suicide in an individual, as indicated by the presence of suicidal ideation, plans, gestures, or attempts.[1] Nowadays, more attention is being paid to the concept of suicidality among the general population, with some emphasis on examining suicidal ideations and behaviors among law enforcement personnel, such as, police officers.[2] Suicidality could occur as a solitary mental health problem, or as an accompanying symptom of mental disorders like: depression, anxiety disorder, post-traumatic stress disorder, and substance abuse.[2] [3] [4] [5] It has been suggested that suicidality should be regarded as an epidemic among police personnel, [6] [7] in some settings, police officers have reported higher levels of suicidality compared to the general population.[3] [8] [9] [10] [11] Indeed, it is ironic, with the Nigerian law which still considers attempters of suicide a crime, yet police officers who are expected to prosecute suicidal persons, also have suicidal tendencies.Also, it is a serious cause for concern that statistics for suicidality appear to be rising steadily among police officers, who are charged with the responsibility of protecting lives and property within the community.[2] Despite the significant prevalence of suicidality among officers of the police force, most cases may be largely undetected for various reasons.For instance, taking into account the tedious nature of police work, officers may require some degree of "macho" persona which unfortunately does not allow for any display of weakness or help-seeking behavior in the event of emotional distress.[12] Adding to that, comparable to most occupational groups, mental illness is still very much stigmatized in police settings, consequently, this may promote non-disclosure of psychiatric morbidity such as: suicidal ideations or suicidal behavior from affected officers.[13] The aforementioned factors may result in underreporting of suicidality, persistence of symptoms, and in time, lead to absenteeism, negligence, and declining work performance among police officers.
In general, the predictors of suicidality in police officers are quite similar to that of the general population, and may be categorized as: personal, economic, or social.[14] Aside this, there are some work-related predictors of suicidality in police officers, namely: frequent exposure to danger, heavy workload, and infrequent leave from work.[4] The relative easy access to firearms, along with the predominance of males in most police force settings (with men generally having higher suicide propensity than women), are also contributory factors to elevated suicide risk rates among police officers.[15] Lagos State, is the most populous state in Nigeria, with a population size of 25 million.[16] As seen in most heavily populated cities of the world, there is a great potential for criminal activities, and other forms of security threats within Lagos.Given this circumstance, Lagos-based police officers may be more prone to work-related stress in comparison with their colleagues in other states of the federation.Beyond this, other peculiar stressors such as: traffic congestion and high cost of living, are commonly experienced by the inhabitants of Lagos, as well as police officers within the state.All of which may increase suicide risk in these officers, among other debilitating mental health problems.
Studies on suicidality and its predictors in police officers have emanated mostly from high-income nations, with minimal data from low-income settings as Nigeria.More so, there is a dearth of studies concerning suicidality and its predictors among police officers in South-West Nigeria, including, Lagos.In light of this, it is necessary to examine the burden and predictors of suicidality in police personnel in Nigeria, as this may allow for easy identification of vulnerable officers, and provide an opportunity for early psycho-social intervention.
Knowing this, our study attempted to determine the prevalence and predictors of suicidality among Nigerian police officers.

Study Design and Participants
This study was conducted between May and June 2023, and the participants were police officers serving at the Police College, Lagos, Nigeria.This was a cross-sectional descriptive study, and inclusion criteria were: those in the junior official cadre, and who gave informed consent for participation.Those with a history of mental illness, and who did not give consent, were excluded.Non-probability convenience sampling was used to select a total of 600 participants.

Study Instruments
Socio-demographic Questionnaire This instrument asked questions concerning the socio-demographic (age, gender, marital status, religion, educational status, job satisfaction) and clinical (history of substance use, family history of mental illness, family history of suicide) profile of the participants.
Suicide Behaviour Questionnaire-Revised (SBQ-R) The Suicide Behavior Questionnaire-Revised (SBQ-R) is a brief self-report questionnaire used to assess for suicide risk.This instrument was designed by Osman et al. [17] based on the original 34-item SBQ developed by Linehan and Nielsen et al. [18] The four-item instrument is brief, and takes approximately five minutes to complete.Each of the four questions addresses a specific risk factor: the first item concerns presence of suicidal thoughts and attempts, the second, concerns frequency of suicidal thoughts, the third concerns the threat level of suicidal attempts, and the fourth concerns likelihood of future suicidal attempts.A maximum score of 18 is possible, and total score of ≥7 indicates significant risk of suicidal behavior.This instrument has an internal consistency of 0.93, [17] and has been validated for use in Nigeria.[19] State-Trait Anxiety Inventory (STAI) The STAI was developed to determine an individual's anxiety levels as a state and a trait.[20] The state subscale (STAI-S) assesses how the individual feels "right now" or at the moment, while, the trait subscale (STAI-T) assesses how the individual generally feels.Each question is rated on a 4-point likert scale (not at all, somewhat, moderately so, very much so).The range of possible total scores is from 20 to 80 on both the STAI-T and STAI-S subscales.Higher scores indicate greater anxiety, as STAI scores are commonly classified as "no or low anxiety" (20 -37), "moderate anxiety" (38 -44), and "high anxiety" (45 -80).
Internal consistency coefficients for the scale have ranged from 0.86 to 0.95.[20] Data Collection The study purpose was explained and informed consent was obtained from eligible participants.

Results
A total of 638 participants met the inclusion criteria, however, only 600 participants completed the instruments, giving a 94% response rate from the sample.

Clinical Profile
About one-third of the sample was engaged in substance use (23%), with alcohol use being the commonest (14%).Family history of mental illness and family history of suicide were reported by 3%, and 5% of the sample respectively (See Table 1).Using the STAI, the mean score and prevalence of state anxiety were 43 (±10) and 38% respectively, while for trait anxiety, a mean of 46 (±9) and prevalence of 22% were recorded (See Table 1 and Table 2).

Prevalence of Suicidality
Using the SBQ-R, the mean score (±Standard Deviation) was 5 (±3), with 14% of the sample screening positive for suicidality (See Table 2).The lifetime-prevalence of suicidal ideation was 22%, 2% of the participants reported lifetime-suicidal attempt with concomitant hope to die.The prevalence of suicidal ideation in the *SD = Standard Deviation.
past year was 21%, with 9.3% having suicidal ideations very often.About 14% of them in their lifetime had declared a suicidal intent to others, and 7% had done this more than once due to having a strong desire to commit suicide.Furthermore, a likelihood of future suicide attempt was found in 6.4% of the sample (See Table 3).

Predictors of Suicidality
To determine the variables independently associated with suicidality, a Chi-Square Test of Independence was done.The following socio-demographic variables had a significant association with suicidality: age, gender, marital status, and education.Clinical variables such as state anxiety, trait anxiety, substance use and family history of suicide were also significantly associated with suicidality.However, family history of mental illness and job satisfaction were not significant (See Table 4).
Using regression analysis, suicidality was made the dependent variable, and significant variables from the Chi-Square Test were made the independent variables.Being female was associated with a 5-fold increased risk of suicidality.Also, with every increase in state anxiety and trait anxiety score, the risk of suicidality was increased by 6-fold and 3-fold respectively (p < 0.001).
Those who were unmarried were three times more likely to be suicidal in comparison to married officers, while those using substance were two times more likely to be suicidal compared to those who did not.However, family history of suicide, education, and age were no longer significant on regression (See Table 4).

Discussion
In summary, there was a 14% prevalence of suicidality among police officers, predictors of suicidality were: anxiety, substance use, being unmarried, and female gender.Table 3. Suicidality profile of the participants using the SBQ-R.

VARIABLE FREQUENCY (%)
A. Have you ever thought about or attempted to kill yourself?

Key Findings
A prevalence of 14 % was found for suicidality among the police officers.In comparison with other African countries, this prevalence was close to the 15% rate recorded in Tanzanian police officers, [5] but was higher than the 10.6% seen in South-Africa.[21] Furthermore, the suicidality rate in this study was also higher than 1.2%, [22] 6.4%, [23] and 10% [24] found in police officers serving in affluent countries like: Italy, Norway, and Canada.The contrast between the suicidality rate of this study and earlier studies may exist due to varying methodology.Beyond this, in comparison to the above listed high-income nations with lower police suicidality rates, Nigeria is resource-poor.This suggests that Nigerian  Being unmarried was associated with a higher suicidal risk in police officers, this had been established previously.[23] [25] [26] [27] Notably, suicide studies on the general population show that unmarried individuals have a proneness to suicidality.[28] [29] [30] [31] It is probable that unmarried persons may not enjoy as much physical support as those who are married.Considering that majority of police officers face a lot of stress while on duty, the absence of a confidante or partner to share ideas, problems, and emotions with, could be detrimental to mental health.
Suicide risk was greater in female officers, this echoes past study outcomes.[2] [23] [26] Diverse explanations have been made for the gender difference in suicidality among police officers.For instance, unlike males, females may be physically and emotionally less suited to police work, therefore, may be easily overwhelmed.In addition, it is the opinion of the authors that there is a likelihood of female officers encountering adversities in the work place such as sexual harassment, gender discrimination, and an unrelenting need to prove themselves worthy of their jobs, this could be emotional draining.Coupled with their official duties, most females have to deal with the extra responsibility of caring for their families, this could predispose them psychological distress.Also, suicidality is commonly reported in depression, a disorder with a female predilection, therefore female officers with depression may have suicidality as one of their symptoms.
Anxiety was a predictor of suicidality, this corroborates findings made by Berg et al., [23] Di Nota et al., [2] and Guerrero-Barona et al. [14] This is an expected finding because, most persons reporting a lifetime history of suicide ideation or attempt usually have a prior diagnosis of anxiety disorder.[32] [33] For police officers, the constant threat of danger and death which accompanies their profession may put them in a state of recurrent tension, leading to anxiety, and in time, suicidality.
Substance use was linked with high suicide risk among the police officers, identical observations were made hitherto.[2] [8] [34] [35] The linear relationship between psychoactive substance use and suicide risk is well-known.[36] [37] [38] Because of the pervasive effect of psychoactive substances on the cognition, mood, and behavior of users, suicidality may understandably be a fall-out of substance use in police officers, thereby limiting their effectiveness at work.

Strengths and Limitations
Given that suicide is viewed as a taboo topic in most African countries, and the rarity of mental health research focused on law enforcement officers within Africa, this study is unique and provides some valuable insight.However, the exclusion of senior police officers is a limitation, possibly, the study findings may have differed considerably if this group of officers were included.The use of self-reporting instruments may have also increased the possibility of selection of socially-desirable responses by the participants.The use of a screening instrument instead of a diagnostic one may have overestimated the prevalence of suicidality.

Clinical Implications
Police officers, especially those at risk for suicide, may require regular suicide risk assessment, this would allow for early identification of vulnerable persons, and the commencement of mental health intervention for those in need of this.

Policy Implications
Our study outcome may provide the Nigerian government and other stakeholders in the Nigerian police force with data which could serve as an advocacy tool for mental health promotion, and suicide prevention activities for Nigerian police officers.Also, the study shows that institution of mental health support units in police commands across the nation, is a necessity.Hopefully, this could translate to a more mentally-healthy Nigerian Police Force, and of course, enhanced maintenance of security, law, and order by police officers in Nigeria.

Future Research Directions
A comparative study on the differences between the burden and predictors of suicidality in junior and senior police officers may be of great interest and value.
A toxicology screening test may be incorporated into future studies to determine the relationship between substance use and suicidality in police officers.Longitudinal studies on suicidality and its predictors in police officers may also be considered.Also, the impact of psychotherapy on suicide risk in police officers is worth exploring.

Conclusion
Police officers play a major role in ensuring a security of lives and properties in every society, suicide prevention, and mental health promotion strategies should be put in place by the leadership of the police force for their officers.
The instruments were administered, and those identified with psychopathology were referred to the Police Mental Health and Counselling Unit of the Nigeria Police Medical Services, Lagos for intervention.
Statistical AnalysisStatistical analysis was done using the Statistical Package for the Social Sciences Version-26.Descriptive statistics of the participants, such as: means, standard deviations, frequencies and percentages were presented.Chi-square Test of Independence was done to determine associations between socio-demographic variables, clinical variables, and suicidality.Variables that were found to be significant on this test (p-value < 0.05) were later included in a logistic regression model (Backward Stepwise Method).The regression analysis was to further examine their relationship with suicidality, and to determine the specific predictors of suicidality.Level of significance was set at p < 0.05 for all the statistical tests.

Table 2 .
Descriptive statistics of the sbq-r and stai.
Exact Value, *DF = degree of Freedom, B = Standardised Co-efficient Value; † N = Frequency, ‡ SIG = Level of Significance; § LB = Lower Border of Confidence Interval, || UB = Upper Border of Confidence Interval.policeofficers may have to contend with more criminal activities, lesser wages, socio-economic hardships, apart from the rigors of police work.Over time, constantly dealing with such stressors may increase suicide risk.