Suicide Awareness and Prevention Campaign

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Events

Watch the Public Campaign Launch Event, held December 4th, 2019, at the Bahen Centre for Information Technology, the location of two suicide deaths this year at the University of Toronto. The event was hosted by the U of T Men’s Issues Awareness Society, with special guest Dr. Dan Bilsker.

Media Coverage

We want to thank those media outlets who have brought attention to this life and death issue.

Post Media coverage “‘Suck It Up’; The sad saga of men and suicide” (December 8, 2019): Read the full page story in the Toronto Sun, Ottawa Sun, Calgary Sun, Edmonton Sun, Winnipeg Sun, London Free Press, or The Province

Danielle Smith Show on Global News: Men are 75% of all Canadian suicides – what can we do to help those suffering? (December 3, 2019)

Media Nation on News Talk Sauga 960AM Radio (December 11, 2019)

Signs of Despair in Men

Men may hide their distress or express it in ways that are not immediately obvious.

The following are questions to ask yourself as you look out for warning signs of despair (the key precursor to suicidality).

• Has he recently experienced a big loss (relationship, work, health)?
• Is he withdrawing from contact with family or friends?
• Has he notably increased his alcohol use?
• Does he express to trusted family members or friends that he feels hopeless?
• Does he have a history of self-harm, threats of suicide or violence when under stress?

A systematic review by researchers found the following [36]:

• Signs of suicidal ideation in men were: social withdrawal, anger and reduced problem solving capacity.
• Signs of suicide attempt in men were: statements of suicidal intent, calmness, anger, apathy, hopelessness, risk-taking and appearing ‘at peace’.
• Signs preceding death by suicide in men were: desperation and frustration in the face of unsolvable problems, helplessness, worthlessness, statements of suicidal intent, and emergence of a positive mood state.
• If a man has suffered a relationship break-down, loss of access to his children or loss of employment, these may be precipitating factors leading to suicidal ideation, as described below.

Recognizing Suicidal Behavior, published by WebMD, provides additional useful information

In the research below, material which is italicized are quoted verbatim from the reference provided.

Rates of Suicide

• In Canada, males accounted for 74.61% of all completed suicides, on average, over the last five years.
• Click here for data on completed Canadian suicides by gender and age for the years 2012-2016 (the last five years period for which gender data is available).
• Click here for detailed Tables of Data on completed Canadian suicides. We thank the Centre for Suicide Prevention for sharing this data. These data sources come from Statistics Canada, coroner’s and medical examiner’s offices across Canada and are compiled by the Centre for Suicide Prevention. They are updated at differing time periods; as such, recent data may be incomplete due to delays in reporting.
• Suicide remains the most common cause of death in men under the age of 35 and remains at record levels among middle-aged men (45–49 years) (Office for National Statistics 2014). In the UK, men currently make up 78% of all suicides (Men’s Minds Matter 2017), which is consistent with suicide rates across other high-income countries (WHO 2017). [5]

Suicide and Gender

• In Canada, the male suicide rate is about 3 times that of women. [2, p.324]
• In the western world, males die by suicide three to four times more often than do females. [1]
• Male rates are greater than female rates at all ages and substantially greater across most of the lifespan. [2]
• Death from suicide or “intentional self-harm” (World Health Organization, 2007) exhibits one of the largest sex differences of any of the major causes of death. Males accounted for 79 percent of the suicide deaths in the U.S. in 2005 (Kung et al., 2008). And suicide was ranked as the 8th leading cause of death for males but was ranked 16th for females in 2004 (Heron, 2007). [3]
• There is a striking gender difference in suicide rates worldwide. According to the World Health Organisation (WHO) data, male suicide deaths exceed female deaths in every country except China (WHO, 2011). This is particularly remarkable given the wide geographical, cultural, religious and other social variations between countries. [4]

The causes of suicide are complex. Many factors are typically responsible for an individual suicide. Nevertheless, there are two major areas that contribute to male suicide, and they are worth emphasizing as we explore interventions that could reduce suicide among this high-risk group.

Men, Suicide and Relationship Break-down

• Studies have reported a higher suicide rate in divorced people [8] [9]
• There is evidence to suggest that one life event strongly associated with suicidal ideation, attempts, and completion is the experience of divorce and separation. [7]
• In one study, divorced or separated males had a 39% higher suicide rate than married males [6]. In another study, divorced men were more than eight times more likely to die by suicide than divorced women (relative risk = 8.36, 95% confidence interval =4.24-16.38). [10]
• After taking into account other factors that have been reported to contribute to suicide, divorced men still experienced much increased risks of suicide than divorced women. They were nearly 9.7 times more likely to kill themselves than comparable divorced women (RR = 9.68, 95% CI = 4.87 to 19.22). [14]
• Results have also shown that while marital status, especially divorce increases the risk of suicide in men, the same cannot be said of women. In other words, the effect of marital status on suicide depends on sex. [15]
• Men are more often the partner to lose their home, children, and family [11]
• In many jurisdictions in the US there seems to be an implicit assumption that the bond between a woman and her children is stronger than that between a man and his children. As a consequence, in a divorce settlement, custody of children is more likely to be given to the wife. In the end, the father loses not only his marriage, but his children. [14]
• A number of coroners’ suicide inquests found that separation from children was a primary causal factor in some cases. [12]
• Loneliness following relationship break-down is a factor, as men tend to have a smaller network of social relationships. Even where men have a number of social contacts, the quality of these relationships might be such that these men are still lonely. Joiner notes that many men do not recognize this loneliness, preoccupied as they are with work, but in difficult times, for example, when a marriage fails, they might be suddenly stuck by their lack of meaningful social support. [13]

Men, Suicide and Education

• Men with low levels of education were significantly more likely to experience suicide than those with 16 years of schooling or more. [18]
• Higher male rates are also associated with underemployment and work instability. [19]
• Compared to men who have more than a high school degree, men who have a high school degree have 40% higher, and men who have less than a high school degree have 47% higher risks of suicide mortality over the follow-up period (Model 3).  Education is not significantly associated with the risk of suicide among women. [16]
• Education as a factor in suicide also has a gender effect. Education offers men greater protection than it does women, including a strong attachment to the labor force over the life course, deeper ties to social and community organizations, and, ultimately, greater social integration. [17]

The Gender suicide Paradox

The gender suicide paradox refers to gender patterns, well known among researchers, in which women engage in higher rates of non-fatal suicidal behaviour while men have a higher rate of completed suicide. Intriguingly, the gender suicide gap widens during puberty, possibly resulting from pressure associated with gender role socialization, since when exposed to similar pressures, eg. in the military, men and women commit suicide at similar rates

• One difficulty with predicting completed suicide based on a reported or observed attempt is associated with the measurement of severity of the attempt and the amount of suicidal intent associated with it. Self-inflicted injuries that are labeled as attempted suicides range widely in severity from a “cry for help” without intent to die to a genuine failed suicide. [20]
• The common explanation for the gender suicide paradox is the “Lethality Theory,” according to which men are more likely to die by suicide because they select more lethal means of committing suicide.  However, the lethality theory is unable to explain why there are more male deaths from methods considered less lethal, such as medication overdose, even though women are more likely to use this method (Australian Bureau of Statistics (ABS), 2012; Bradley & Harrison, 2008). Furthermore, why are women who use the same methods as men still less likely to die (Elnour & Harrison, 2008)? Elnour and Harrison suggested that the lethality explanation is incomplete since it reveals nothing about the underlying factors that lead to the choice of suicide method. Canetto and Sakinofsky (1998, p. 20) argued that a “cultural scripts theory” could account  for preference of method and for the variation in male and female fatality rates when the same method is used. [4]

The research of Silvia Sara Canetto (Colorado State University) and Isaac Sakinofsky (University of Toronto) is helpful [20] in analyzing competing theories

• “Lethality Theory” fails to address intention and to explain why both men and women both prefer the use of firearms, a highly lethal method, although men do use other lethal methods more often than do women [For more on the problems with Lethality Theory, see [20, p.9]
• Another explanation to account for differential gender rates may be gender differences in socialization. According to this explanation, there are gender differences in culturally acceptable self-destructive behaviors (56). Men are less likely to attempt suicide because attempts are considered “feminine.” At the same time, men are more likely to engage in “masculine” self-destructive behaviors such as alcohol and other drug abuse, or use more aggressive and lethal methods of self-destruction (57). [20,p17]
• A related theory is known as Cultural Scripts theory, in which men and women follow different cultural scripts in response to suicidal ideation, with men engaging in alcohol and substance abuse and women in nonfatal suicidal behaviour. This may result in masking the suicidal ideation of men. [20]
• It is also possible that recall bias partly explains the appearance of fewer acts of non-lethal suicidal behaviour by men. Lifetime data are subject to recall bias, since they are heavily dependent on a person’s ability to remember important events. Since women are generally considered to be better reporters of health history than are men, as well as more frequent users of health services, the higher lifetime rates of attempted suicide among women may not represent patterns of recently attempted suicide in the population. [20, p8,p14]

Canadian Psychologist and Clinical Assistant Professor in the Faculty of Medicine at the University of British Columbia Dan Bilsker has published A Roadmap to Men’s Health, which offers insights in this area [2]:

• Although men die by suicide at a higher rate, women have a higher rate of attempting suicide… It should be noted that there is a spectrum of self-harm, ranging from acts of physical self-harm not intended to be suicidal, to acts that reflect ambivalence about dying, to acts that reflect a clear and settled intention to die. The broad term Deliberate Self-Harm [DSH] is used in the research to capture this range of possible actions. As one might expect from the suicide attempt statistics, women show much higher rates of DSH. [2, p.85]
• From a behavioural point of view, we could ask why men are more likely to choose methods of high lethality. With regard to the use of firearms, it may be that men have more exposure to guns and thus are more prone to this method. But when it comes to hanging, it is not clear why men would find this method more acceptable. We can speculate about other reasons men may have for employing highly lethal means. It may be that men who reach the point of suicidal action are more hopeless than are women; more clearly resolved to die; more likely to be intoxicated and thus more disinhibited; more willing to carry out actions that might leave them injured/disfigured; less concerned with consequences due to a high risk-taking orientation; etc. [2, p.87]
• It is well recognized that males tend to use violent means of both suicide and DSH more often than do females. Greater suicidal intent, aggression, knowledge regarding violent means and less concern about bodily disfigurement, are all likely explanations for the excess of violent suicide in males. [2, p87]
• From the perspective of behavioural risk for suicide in men, a study of suicide attempts in older men and women showed that men were more intent upon dying and moved more quickly and “decisively” from considering suicide to acting upon the suicidal ideation. The study noted that, “Our findings suggest that factors responsible for the increased suicide rate in older men operate largely during the suicidal crisis itself: once a depressed older man develops serious suicidal intent, he tends to realize it with little hesitation.” [2, p.88]

Research from other nations concurs, as in the research of Dr. Anne Maria Möller-Leimkühler, Department of Psychiatry, Ludwig-Maximilians-University, Germany [21]

• As a number of studies in the U. S. have shown, surviving a suicidal act is culturally perceived as an inappropriate behaviour for males (Canetto 1997). For example, college students have shown to be most unsympathetic towards suicidal males (White, Stillion 1988), which is an evaluation leading suicidal males to choose more lethal methods like firearms or hanging. Death by suicide in males was rated as less wrong, less foolish and less weak than death by suicide in females (Deluty 1988–1989);men who killed themselves were seen as more well-adjusted than women, particularly when they committed suicide because of an athletic failure, and not because of a relationship failure (Lewis, Shepeard 1992).These gender-specific cultural beliefs and attitudes towards self-destructive behaviour may contribute to the explanation of young men’s low rates of parasuicidal behaviour and their high rates of suicide mortality. However, as recent data from the UK indicate, the female to male ratio of parasuicidal behaviour has fallen from 2:1 to 1:1, apparently due to a rise in parasuicidal behaviour in young men (Hawton et al. cit. McQueen, Henwood 2002). [21]

Help seeking Behaviours, Coping Techniques and Use of services

• A review of help-seeking by individuals who eventually died by suicide showed that men had much lower rates of contact with healthcare. [2]
• 75 % of those who sought professional help in an institution for suicide prevention were female, and 75 % of those who committed suicide in the same year were male. [21]
• Men of different ages, nationalities and ethnic backgrounds seek help from mental health services less frequently than women from comparative groups compared male and female experiences of depression. [23] [24]
• To hide their depression men rely on norm-congruent behaviour like aggressiveness, anger attacks, acting out, low impulse control and alcohol abuse, a gender-related response pattern that has been hypothesised as the ‘male depressive syndrome.’ [22]
• From an early age, caregivers appear to conform to cultural gender norms and unwittingly respond differently to boys and girls, subtly reinforcing gender consistent expressions of emotion. [25]

What Can You Do?

Individuals

1. Look behind the mask – see the uniquely male signs of depression and suicidal ideation.
2. Reframe help-seeking as a sign of strength and as a preventative action in order to encourage men to get help. [5]
3. Encourage boys and men to disclose distress to friends and family, as many men are more willing to open up to friends and family than to professional healthcare personnel.
4. For parents, teachers and others who come into contact with young people, treat boys and girls the same from the earliest age.

Agencies

Wholesale change to existing evidence-based practices are unlikely to be needed to meet the needs of men. What is more likely required is a gender sensitive approach in the delivery of the intervention and sensitive engagement at the right entry point for different men in their psychological journey. By doing so we are likely to improve men’s engagement with the available evidence-based therapies. [5]

1. Agencies that offer interventions to those at risk of suicide must identify men as a high risk group and design intervention programs that men will use.
2. Nurture connections between depressed men and health professionals through acceptance of ‘guarded vulnerability’ until trust is established and working with men as equals in a partnership.
3. Gender-sensitive language and male specific material is important. [28] For example, use terms such as ‘stress’ rather than ‘mental wellbeing’ because it externalises the problem and may be more acceptable to men. Men should feel in control of the service rather than be expected to fit in and feel disempowered. [27] The charity, Samaritans, improved their engagement of male callers by training staff in how to speak to male callers. [5] Services designed specifically for men, such as CALM, Men’s Health Forum and Men’s Minds Matter have been successful in engaging men in mental health conversations, partly due to the gender sensitive language used and their non-psychiatric focus.
4. Using concepts men use could be very helpful. Results from a large European study indicate that men often attribute depressive symptoms to work stress or physical illnesses, particularly heart and blood pressure problems, whereas women attribute depression to relationship problems or illness/death in the family. The tendency to somatise psychological experience may occur more frequently in men, as it is likely to be linked to poor emotional awareness. Thus, marketing interventions that address these concerns may also improve engagement. [31] [32]
5. Help men feel in control of the service offered by empowering men to choose their preferred treatment plan. [33]
6. It has been suggested that men have a preference for short-term, directive goal-oriented, action-focused interventions based on problem-solving strategies… Interventions that do not conform to traditional ‘talking’ therapy such as using physical and/or leisure activities can also appear to be engaging and effective. [29] [30]
7. There is some evidence to suggest that men are more willing to access help-lines and online text support. Tis appears to be particularly important when a gender sensitive approach is used. [5]
8. Specialist support for men undergoing separation and divorce should be considered a suicide prevention strategy. This can occur through the official mental health system, or through funded voluntary organizations which can provide peer support. [34]
9. Male-specific screening for professionals eg. drug use, early parental separation, family history of suicide. According to Dr. Dan Bilsker, Another study tracked individuals with the diagnosis of major depression over two years and found certain variables to be much more predictive of suicidal acts in men than in women: a family history of suicidal behaviour, previous drug use, and early parental separation.ccclii As noted above, substance abuse is more associated with suicidality in men and this should be a key component of male suicidality assessment. [2, pg.89]

Researchers

• There is a pressing need for research on the precipitating and predisposing factors that distinguish male suicide and can account for the substantial gender disparity in death by suicide. Why do men use more lethal methods, why do they move with less hesitation from thinking about suicide to implementing it, why are they more reluctant to seek help in dealing with the stressors that contribute to suicidality, etc.? A richer understanding of the pathways to suicide characteristic of men will give us a stronger basis for designing programs to prevent suicide in the general population or the subpopulation of individuals with identified mental health problems. [2]
• Research that carefully examines the chain of predisposing and precipitating events leading to suicide attempts in men and women, perhaps within a qualitative research format (including interviews or focus groups to elicit typical stories of how people became suicidal), would be very informative. This research method would help us to answer crucial questions: What are the behavioural chains leading to suicide in men? How are these chains different from those characteristic of women? How might one interrupt these chains in order to prevent their tragic outcomes? [2]
• As explored above, mounting evidence suggests that two social factors can increase the risk of male suicide. These are (i) occupational and employment issues and (ii) divorce and relationship breakdown. A better framework to understand male suicide maybe a public health framework known as ‘the social determinants of health’. This involves documenting and analyzing a range of social factors, examining their impact on health outcomes through rigorous research. [34]

 

References

[1] Värnik, P (March 2012). “Suicide in the world”. International Journal of Environmental Research and Public Health. 9 (3): 760–71. doi:10.3390/ijerph9030760.

[2] Bilsker, D., Goldenberg, L., Davison, J. (2010). A roadmap to men’s health: Current status, research, policy & practice. https://www.sfu.ca/carmha/publications/roadmap-to-mens-health.html

[3] Denney, J., Rogers, R., Krueger, P., Wadsworth, T. Adult Suicide Mortality in the United States: Marital Status, Family Size, Socioeconomic Status, and Differences by Sex. Soc Sci Q, 90(5): 1167-1185.

[4] Lester, D. (2014). Suicide in Men: How men differ from women in expressing their distress. Springfield, IL: Charles C Thomas.

[5] Brown J.S.L., Sagar-Ouriaghli I., Sullivan L. (2019) Help-Seeking Among Men for Mental Health Problems. In: Barry J., Kingerlee R., Seager M., Sullivan L. (eds) The Palgrave Handbook of Male Psychology and Mental Health. Palgrave Macmillan, Cham

[6] Denney, J., Rogers, R., Krueger, P., Wadsworth, T. Adult Suicide Mortality in the United States: Marital Status, Family Size, Socioeconomic Status, and Differences by Sex. Soc Sci Q, 90(5): 1167-1185.

[7] Scourfield, J, Evans, R. (2014). Why Might Men Be More at Risk of Suicide After a Relationship Breakdown? Sociological Insights, American Journal of Men’s Health, 1–5.

[8] Cutright, P., Fernquist, R. M. (2005). Marital status integration, psychological well-being, and suicide acceptability as predictors of marital status differentials in suicide rates. Social Science Research, 34, 570–590.

[9] Stack, S. (2000b). Suicide: A 15 year review of the sociological literature: Part II: Modernization and social integration perspectives. Suicide and Life Threatening Behavior, 30, 163–176.

[10] Kposowa, A. J. (2003). Divorce and suicide risk. Journal of Epidemiology & Community Health, 57, 993–995.

[11] Payne, S., Swami, V., Stanistreet, D. L. (2008). The social construction of gender and its influence on suicide: A review of the literature. Journal of Men’s Health, 5(1), 23–35.

[12] Shiner, M., Scourfield, J., Fincham, B., Langer, S. (2009). When things fall apart: Gender and suicide across the life course. Social Science & Medicine, 69, 738–746.

[13] Joiner, T. (2011). Lonely at the top: The high cost of men’s success. New York, NY: Palgrave Macmillan.

[14] Kposowa, AJ. (2000). Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol Community Health 54, 254–61.

[15] Kposowa, AJ. (2000). Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol Community Health 54, 254–61.

[16] Denney, J., Rogers, R., Krueger, P., Wadsworth, T. Adult Suicide Mortality in the United States: Marital Status, Family Size, Socioeconomic Status, and Differences by Sex. Soc Sci Q, 90(5): 1167-1185.

[17] DiPrete, T.; Buchman, C. (2006) Gender Specific Trends in the Value of Education and the Emerging Gender Gap in College Completion. Demography. 41, 1-24.

[18] Kposowa, AJ. (2000). Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol Community Health 54, 254–61.

[19] Fairweather, A. K., Anstey, K. J., Rodgers, B., Jorm, A. F., & Christensen, H. (2007). Age and gender differences among Australian suicide ideators, prevalence and correlates. Journal of Nervous & Mental Disease, 195, 130–136.

[20] Canetto, S., Sakinofsky, I. (1998). The Gender Paradox in Suicide. Suicide Life Threat Behav. 28(1), 1-23.

[21] Möller-Leimkühler, A. (2003). The gender gap in suicide and premature death or: why are men so vulnerable?, Eur Arch Psychiatry Clin Neurosci, 253, 1-8.

[22] Rutz, W., von Knorring, L., Pihlgren, H., Rihmer, Z., Walinder, J. (1995). revention of male suicides: lessons from Gotland study. Lancet, 345(8948), 524.

[23] Addis, M., Mahalik, J. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58, 5–14.

[24] Emslie, C., Ridge, D., Ziebland, S., Hunt, K. (2006). Men’s accounts of depression: Reconstructing or resisting hegemonic masculinity? Social Science and Medicine, 62(9), 2246–2257.

[25] Fivush, R., Brotman, J. , Buckner, J. , Goodman, S.. (2000). Gender differences in parent-child emotion narratives. Sex Roles, 42, 233–253.

[26] Oliffe, J., Ogrodniczuk, J., Bottorff, J., Johnson, J., Hoyak, K. (2012). “You feel like you can’t live anymore”: Suicide from the perspectives of Canadian men who experience depression. Social Science & Medicine, 74, 506-514.

[27] Pollard, J. (2016). Early and efective intervention in male mental health. Perspectives in Public Health, 136(6), 337–338.

[28] Hammer, J., Vogel, D. (2010). Men’s help seeking for depression: The efficacy of a male-sensitive brochure about counseling. Te Counseling Psychologist, 38(2), 296–313.

[29] Emslie, C., Ridge, D., Ziebland, S., Hunt, K. (2007). Exploring men’s and women’s experiences of depression and engagement with health professionals: More similarities than diferences? A qualitative interview study. BMC Family Practice,
8(1), 43.

[30] Kingerlee, R., Precious, D., Sullivan, L., Barry, J. (2014). Engaging in the emotional lives of men. Te Psychologist, 27(6), 418–421.

[31] Angst, J., Gamma, A., Gastpar, M., Lépine, J. P., Mendlewicz, J., Tylee, A. (2002). Gender diferences in depression. European Archives of Psychiatry and Clinical Neuroscience, 252(5), 201–209.

[32] Englar-Carlson, M., Kiselica, M. S. (2013). Affirming the strengths in men: A positive masculinity approach to assisting male clients. Journal of Counseling & Development, 91(4), 399–409.

[33] Cheshire, A., Peters, D., Ridge, D. (2016). How do we improve men’s mental health via primary care? An evaluation of the atlas men’s well-being pilot programme for stressed/distressed men. BMC Family Practice, 17(1), 13.

[34] Whitley, R. (Sept 24, 2019). Preventing Male Suicide: A Social Determinants Approach. Psychology Today. Retrieved from  https://www.psychologytoday.com/ca/blog/talking-about-men/201909/preventing-male-suicide-social-determinants-approach

[35] Bilsker, D., White, J. (2011). The Silent Epidemic of Male Suicide, BCMJ, 53(10), 529-534.

[36] Hunt, T., Wilson, C., Caputi, P., Woodward, A., Wilson, I. (2017). Signs of current suicidality in men: A systemic review. PLoS One. 12(3).