The American Psychiatric Association (2019) defines suicide as ‘the act of killing yourself, most often as a result of depression or other mental illness’. However, Oquendo and Baca-Garcia (2014) argue that, although suicidal behaviour often occurs in the context of mental illness, this is not always the case. Only half of those who die by suicide have previously been referred to mental health services (National Confidential Inquiry, 2013) and one study found that 37% of primary care patients who die by suicide had never received a diagnosis of a mental illness (National Confidential Inquiry, 2014). The World Health Organization (2019) explains that suicides can occur impulsively in times of crisis when the person is unable to cope with stress. Causes of stress may include monetary problems, relationship issues and chronic pain and illness. They also list high rates of suicide among people who have experienced conflict, disaster, violence, abuse, loss and a sense of isolation; and those who experience discrimination (including refugees and migrants; indigenous peoples; lesbian, gay, bisexual, transgender, intersex [LGBTI] persons; and prisoners).
In England and Wales, suicide is recorded by a coroner, who is either medically or legally qualified, following an inquest. Until recently, a verdict of suicide was only given if the evidence indicated suicidal intent beyond reasonable doubt (Matthews and Foreman, 2014). This is the criminal standard. However, in May 2019, the Court of Appeal in England and Wales ruled that the standard of proof required for a suicide conclusion should be the civil standard, and therefore will be reached on the ‘balance of probabilities’. This lowering of the threshold is expected to lead to an increase in the number of deaths recorded as suicide (Appleby et al, 2019). The conclusion of an inquest (previously verdict) is sent to the Office for National Statistics (ONS) who are responsible for collecting and publishing official statistics about society and the economy in the UK. The ONS notify the National Confidential Inquiry (NCI) who use the data to identify those who have been in contact with services in the year prior to death.
Rates of suicide
The ONS (2019) report states that there were 6507 suicides in the UK and 352 in Ireland in 2018, and that the UK male suicide rate of 17.2 deaths per 100 000 represents a significant increase from the rate in 2017. Figures from Public Health England (2019) show the suicide rate for males in England was 14.7 per 100 000 people compared to 4.7 per 100 000 in females.
The Samaritans is a charity whose vision is to reduce the number of people dying by suicide. They collate suicide statistics for the UK and Ireland and publish them annually in their Suicide Statistics Report (Samaritans, 2019). In this report they describe how men in the UK are three times more likely to take their own lives than women, and in Ireland, they are four times more likely. The highest suicide rate for men in the UK is in the age group 45–49 years (ONS, 2019).
Why are men more likely to die by suicide?
Researchers have several theories as to why men are more likely to die by suicide. Maleness, methods of self-harm, relationship breakdown and the challenges of mid-life are among some of the explanations offered.
Maleness
A shared theory is based on the idea of ‘maleness’ that has been created and accepted by society, which classifies the dominant social position of men and the subordinate social position of women (Connell and Messerschmidt, 2005). Literature describing male gender roles highlights greater levels of strength and independence (Payne et al, 2008). This may prevent men from seeking help for suicidal feelings and depression (Möller-Leimkühler, 2002). Additionally, men are much less likely than women to have confidence in counselling or therapy on offer; so when they choose to use these services, it is often at the point of crisis (Wylie et al, 2012). Women are more likely to use social support and seek psychiatric or other medical intervention, which may prevent them from committing suicide (Stack, 2000; Oliver et al, 2005). A man's vulnerability may be increased if he becomes unemployed because of gendered expectations that men should provide for themselves and their families (Möller-Leimkühler, 2002).
Methods of self-harm
The methods of self-harm selected have been cited as a reason for the higher incidence of suicide in men than women; for example, men tend to use methods of self-harm which are potentially more lethal and dangerous (Payne et al, 2008). They are more likely than women to respond to stress by taking risks or misusing alcohol and drugs, which increases their risk of suicide (Wylie et al, 2012; Department of Health, 2012).
Relationship breakdown
Men are more likely to die by suicide following a marriage breakdown than women (Scourfield and Evans, 2015). This could be because they rely more on their partners for emotional support and/or expect to be dominant in their relationship (Wylie et al, 2012). Some suicides in men are driven by the wish to punish their ex-partner or may be a response to their ex-partner beginning a new relationship (Shiner et al, 2009). Men are more likely than women to be separated from their children; one UK study showed 46% of men aged 45–54 years have non-residential children (Falkingham et al, 2012). This has been cited as both a factor and primary causal factor in a number of coroners’ suicide inquests (Shiner et al, 2009).
Challenges of mid-life
All middle-aged people are facing more mental health problems and unhappiness compared to younger and older people (ONS, 2019). The way men in mid-life manage their emotional lives and their attitudes to support services may be affected by being part of a ‘buffer’ generation; meaning they are fixed between their traditional, strong, silent, austere fathers and their progressive, individualistic sons (Mannheim, 1952), or to put it another way, the difference between the pre-war ‘silent’ and the post-war ‘me’ generations (Anderson and Brownlie, 2011).
Studies have shown that over 90% of people whose death was due to suicide had been in contact with primary care in the year prior to death
Middle-aged men are less likely than women to have supportive friendships and often depend on their female partner for emotional support (Wylie et al, 2012). Around 75% of men aged 45–54 years who live alone have been in a previous partnership and those who have never had a partner are considerably more economically disadvantaged than their female counterparts (Falkingham et al, 2012).
Recognition of suicide risk by primary care staff
Studies have shown that over 90% of people whose death was due to suicide had been in contact with primary care in the year prior to death (Luoma et al, 2002; Pearson et al, 2009; National Confidential Inquiry, 2014). Patients with a psychiatric history have higher rates of consultation and consult closer to the time of their death (Pearson et al, 2009); but only a quarter of those who die by suicide have been in contact with mental health services in the year prior to death (National Confidential Inquiry, 2013).
In 2012 the Government developed a strategy with the aim to reduce the suicide rate and improve support for those affected by suicide (Department of Health, 2012). It advocates important areas for action, describes what government departments will do, and provides explanations about high risk groups, effective interventions and resources to support local action. It discusses the importance of the role of primary care in preventing suicide, as GPs are often the first health professionals seen by people who are experiencing distress or suicidal thoughts, and mental illness is principally managed in primary care. There is a need to raise awareness among all general practice staff, as mental illness is unrecognised in two-thirds of primary care patients (Mitchell et al, 2009). A qualitative study of relatives and close friends bereaved by suicide and GPs who have experienced the suicide of patients (Leavey et al, 2017), found failures in the recognition and management of suicidal patients, and perceived structural inadequacies in service provision. The researchers carried out interviews with GPs about patients who died by suicide and found that only 16% of them thought that the suicide could have been prevented.
‘Men in the UK are three times more likely to take their own lives than women, and in Ireland, they are four times more likely. The highest suicide rate for men in the UK is in the age group 45–49 years.’
Suicide rates have been associated with physical illness (Webb et al, 2012); but many people living with a long-term condition (physical illness, disability and chronic pain) have depression which is undiagnosed and, therefore, untreated (Department of Health, 2012). Young people attending primary care for self-harm have a significantly increased risk of suicide (Morgan et al, 2017). Only a small proportion of self-harm occurs in older people, but those who do self-harm have a high risk of suicide (National Institute for Health and Care Excellence, 2004). There is evidence to suggest that the clinical management of older adults who self-harm needs to improve, particularly around providing referrals to mental health specialists (Morgan et al, 2018).
Preventing suicide
One means of reducing suicide is to improve the mental health of the whole population. In 2010, the Government gave a greater role to local government and local partnerships in delivering improved public health outcomes, including local responsibility for coordinating and implementing work on suicide prevention (Department of Health, 2010). In their report, ‘No Health Without Mental Health’ (Department of Health, 2011), the Government recommends a variety of evidence-based treatments and interventions to prevent people of all ages from developing mental health problems and advise services to be sensitive to the ways in which men present mental health problems.
One example of prevention is the new NHS campaign ‘Every Mind Matters’ which aims to help everyone to manage and maintain their mental health. It suggests simple actions and steps everyone can take to help manage feelings of stress, anxiety, low mood, or when they are struggling to get to sleep (NHS, 2019).
The role of policymakers
Wylie et al (2012) make recommendations to ensure fewer middle-aged men take their own lives. They advocate that policymakers should:
- Ensure national and local suicide prevention strategies target men at the highest risk and consider gender and socio-economic disadvantage
- Design and prioritise interventions to mitigate stereotypes around masculinity and stigma around help-seeking
- Put in place ambitious policies to tackle the risk factors that can be linked to suicide risk in middle-aged men, including loneliness and alcohol misuse
- Roll out suicide awareness training programmes for GPs to improve diagnosis and signposting to services.
The role of health professionals in primary care
Health professionals working in primary care should undertake suicide prevention education. Studies by the London School of Economics have shown that this can have an impact as a population level intervention to prevent suicide (Department of Health, 2012).
The National Confidential Inquiry (2018) provides guidance for health professionals to deliver safer care for people with depression in primary care. They state there should be:
- A mechanism in place to ensure that patients who present with major physical health issues are assessed and monitored for depression and risk of suicide
- A mechanism in place to ensure that patients with certain markers of risk (for example frequent consultations, multiple psychotropic drugs and specific drug combinations) are further assessed and considered for referral to specialist mental health services
- A standard procedure in place for mental health staff to regularly review care with GPs or specialist clinics
- Specific measures in place to reduce suicide risk in men with mental ill-health, including access to services and interventions that are available online and in non-clinical settings (eg sporting communities).
In the author's opinion, the risk of suicide in men attending primary care services may be reduced if practice nurses and primary healthcare staff:
- Are educated in the prevention, recognition and treatment of depression, and suicide prevention
- Are trained to ask the appropriate questions about intention to harm or kill oneself (Box 1)
- Consider depression and stress when consulting with men with long-term physical health problems
- Are alert to behaviours such as self-harm and misuse of alcohol and drugs
- Provide lifestyle advice including sleep, stress management, diet, social life, physical activity and relationships
- Signpost to online support (Box 2)
- Are aware of local services and advertise these verbally and by poster display
- Display posters which may prompt men to talk (Box 3).
Box 1.Suicide questions
- Have you made a suicide attempt in the past?
- Do you think that life is not worth living?
- Do you think about harming or killing yourself? Have you got a plan to kill yourself? How would you do it?
- Do you aim to carry out this plan?
- Have you got access to (the necessary tools to) carry out the plan?
- What would stop (or is stopping) you from carrying out your plan?
Box 2.Online support for men
- HEADSUPGUYS: https://headsupguys.org/take-action/practical-tips/
- HelpGuide: https://www.helpguide.org/articles/depression/depression-in-men.htm
- Royal College of Psychiatrists: https://www.rcpsych.ac.uk/mental-health/problems-disorders/depression-and-men
- CALM: https://www.thecalmzone.net/
- National Self Harm Network: http://nshn.co.uk/
- Every Mind Matters: https://www.nhs.uk/oneyou/every-mind-matters/
Box 3.Posters
- Grassroots (downloadable): https://www.prevent-suicide.org.uk/alright_mate_mens_suicide_prevention.html
- Stop Suicide: https://www.stopsuicidepledge.org/wp-content/uploads/2018/10/S-Word-Campaign.pdf
- MindOut (for LGBTQ): https://www.mindout.org.uk/resources/
- Men's wellbeing manual: https://www.menshealthforum.org.uk/beat-stress-feel-better
Conclusion
Health professionals in primary care can contribute to the prevention of male suicide by ensuring they have the appropriate mechanisms in place in their practice. They need to be aware of which men may be at risk and of the interventions available. In order to achieve this, they need to be enabled to undertake appropriate education and training. Displaying information about depression and suicide and learning how to open discussions about these issues could encourage men to talk about their problems.
Box 4.Resources for professionals
- Self-harm: http://www.eduserve.co.uk/media/455295/professionals-pack.pdf
- Toolkits and guides for GPs and primary care: https://www.cwmt.org.uk/resources-for-gps
- Suicide toolkit for mental health services and primary care: https://bit.ly/31iBxKd
- Suicide and Self-harm Prevention eLearning modules: https://www.minded.org.uk/Component/Details/586395
CPD reflective practice
- How are people with long-term physical problems assessed for depression in your practice?
- Are you aware of any specific measures in your practice which aim to reduce suicide risk in men with mental ill-health (eg access to services and interventions that are available online and in non-clinical settings)?
- Has this article made you think about what happens in your practice? Consider what could be improved
KEY POINTS
- Men are three times more likely than women to die by suicide
- The highest suicide rate for men in the UK is in the age group 45-49 years
- Men are more likely to die by suicide following a marriage breakdown than women
- Most people who died by suicide had been in contact with primary care in the year prior to death
- There is a need raise suicide awareness in primary care to improve diagnosis and signposting to services