With self-induced death rates rising 21.1 percent between the years 2000 and 2012, the Centers for Disease Control and Prevention recently decided to look at the incidence of suicide in a unique way — by profession.

It’s widely known that the rates of suicide for veterans are high, with an average of 22 suicides per day — and law enforcement officers average one suicide every 17 hours. But no one expected the top category among men to be the farmer, fisherman, or forestry worker.

In the most at-risk jobs, it may be difficult to speak up, due to gender norms, professional restrictions or isolation.

In the study group of suicide victims, 77.2 percent were male and 22.8 percent were female. And several themes emerged from the startling research.

The most obvious commonality among the professions ranking high in suicide was stress. When a person’s performance is under constant scrutiny, especially in the pressure of a quickly moving environment, stress is ever-present. In addition, these professions don’t offer a lot of avenues to deal with that stress.

All of the top jobs involved cultures in which it might be difficult to speak up, due to gender norms, professional restrictions, or isolation. Farmers, fishermen, forestry workers, and construction workers often toil alone. If they report to a foreman, it may be in a top-down leadership model, one in which what the boss says is the final word, with little input or feedback. It’s common for a code of behavior to flourish — one that values “manning up” and never complaining.

Women in protective services — the list leader for females — often encounter pressure to “measure up” to male counterparts in traditionally male jobs and environments.

“No matter how informed management might be, there are about 25 male voices countering what I say,” said police officer Edie Cain (not her real name), of Eau Claire, Wisconsin. “When you call attention to some really emotionally difficult sh** you encounter, it’s often a cursory ‘deal with it’ [response] that you receive,” she added.

Nurses comprise a major part of the third-highest impact area for women. They report feeling tremendous pressure to make critical life-affecting decisions and have little to say about their heavy patient loads. Many of them see a stark division in the respect that they receive, compared to doctors.

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“I’ve worked in hospitals for over 25 years,” nurse Tammy Hunter of San Diego, California, told LifeZette. “There always seems to be a deference to the doctors, even when they have made a poor decision. It’s hard to speak up when you feel you’re being unfairly criticized by an oversized ego. Management will back the doctor 98 percent of the time.”

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Doctors, too, have challenges in the workplace. They have the lowest mortality rates — possibly due to their knowledge and access to health care — until it comes to suicide. Burnout among physicians is causing suicide rates to soar, said Suvas Vajracharya, Ph.D., founder and CEO of Lightning Bolt Solutions in South San Francisco, California. His company designed a scheduling software for doctors, which seeks to balance work and personal life.

“Studies show male physicians have a 70 percent higher risk of suicide compared to the general population, and the risk is between 250 to 400 percent higher for women physicians,” he noted. “The number of patients physicians are expected to care for in a day, at record pace, combined with the greater roles they are expected to take on, is taking its toll. Doctors also have a bit of the ‘Iron Man’ mentality that causes them to suffer in silence.”

[lz_bulleted_list title=”Suicide by Profession (Females)” source=”http://www.cdc.gov”]Protective services (police, firefighters, military)|Legal|Health care|Computer and mathematical|Arts, design, entertainment, media[/lz_bulleted_list]

While the latest numbers don’t put doctors at or even near the top of the list, many say it’s because suicide in the medical profession often goes unreported.

Pressure on Relationships, Finances
Many professions on the list are believed to work against relationships and financial stability. It can be difficult to determine if financial challenges come first and put pressure on the relationship, or if key relationships suffer due to some aspect of the job — such as difficult schedules and mandatory overtime.

Seasonal work, with periods of layoffs, is common in construction, fishing, farming, and forestry. Overnight hours, shift work, and mandatory overtime affect protective services and health care greatly.

The pressure of unknown or unpredictable finances can weigh heavily on those who work seasonally, or who may encounter challenges beyond human control. Workers who are laid off may also have limited access to help, if insurance lapses or changes quite often.

Sleep Deprivation
All highly stressful occupations have an impact on sleep. New research published in the Journal of Clinical Psychiatry in June 2016 found that being awake at night confers greater risk for suicide than being awake at other times of day. People who work non-traditional hours and sleep during the day get less deep sleep than night-sleeping counterparts, which can put them at greater risk for the psychological problems stemming from sleep deprivation.

Sleep affects stress, outlook, mood, motivation, resilience, focus, judgment, relationships, job satisfaction, problem solving, risk-taking — as well as substance abuse.

[lz_bulleted_list title=”Suicide by Profession (Males)” source=”http://www.cdc.gov”]Farming, fishing, and forestry|Construction|Installation, maintenance, repair|Production|Architecture/Engineering[/lz_bulleted_list]

Pharmaceutical drugs used for stress, anxiety, and depression can affect sleep, too. Combining drugs may have greater impact on mood and sleep as well.

Thirty-four percent of Americans take at least one pharmaceutical drug, with 11.5 percent taking two or more drugs consistently. The average drug has 70 potential reactions, even if not combined. Not surprisingly, drug use goes up by income and stress level.

Environmental, Chemical Factors
Researchers question the chemical impact on farmers, firefighters and those involved in installation, maintenance and repair. Many chemicals, like those found in fertilizers and solvents, can lead to neurotoxic damage and depression, with long-term exposure.

The study made an immediate impact on industries affected. The construction industry issued a suicide prevention blueprint to instruct contractors about the importance of mental health in the workplace. It emphasizes open discussion of sensitive issues, and several summits have been arranged to educate and instruct management involved in construction. The National Action Alliance for Suicide Prevention has developed special assistance programs as well.

Warning Signs
Unlike many other causes of death, suicide is preventable and thoughtful attention to family, friends, and community members is essential to reducing its impact. If you notice a change in sleep patterns, isolation or avoidance — these are key indicators there may be issues. Avoiding a key emotional topic is common in post-traumatic stress disorder, where remembering trauma is painful and thus avoided. Refusing to discuss any stressor or stressful situation is a sign it is not being addressed.

Related: More Suicides in U.S. — Boomers Especially at Risk

Sleeping a great deal can also be avoidance, while lack of sleep can be a sign the stress is beyond a person’s coping skills. Experts emphasize dealing with the root cause of disrupted sleep, rather than simply medicating it. Additionally, experts recommend that those involved in isolated professions balance their level of interaction throughout a week to be socially involved. Connection to qualified medical help is also absolutely necessary.

Pat Barone, MCC, is a professional credentialed coach and author of the Own Every Bite! bodycentric re-education program for mindful and intuitive eating, who helps clients heal food addictions.