Content warning: this piece explores issues of mental health disorders and suicidality. It goes without saying that if you’re struggling to cope, please seek help. Useful resources can be found on https://www.nhs.uk/conditions/suicide/ and NHS 111 option 2 can help in a mental health crisis.
In 2019, over four thousand men took their own lives in England and Wales (1).
Why is this number so high?
It can be easy to put our clinical hats on and think of “classic” patient vignettes:
55 year old male, recently divorced, with a past medical history of anxiety well-controlled with sertraline. He has a family history of lung cancer so has never smoked, but he drinks 14 units of alcohol a week. Which aspect of his history represents the biggest risk factor for a suicide attempt?
This patient is recently divorced which could make him isolated and drive a low mood. It also could explain his alcohol use. If that were the answer, I’d probably pick it.
Yet, we know nothing about the patient’s upbringing, his wider relationships, the factors that led to his divorce, his current support network or his genetic susceptibility to mental health disorders and suicide.
We often head to a single, pigeonholed factor but forget that suicide is not a fleeting, knee-jerk response in an otherwise healthy person. It is the insidious intersection between many factors, exacerbated by stressors and key events. Crucially, suicide represents a shortcoming of the system and society, not of the person themselves. In fact, the conflation between suicidal thoughts and “weakness” is something that especially plagues the medical profession, right from the days of medical school.
Regarding men specifically, the rates of suicide remain strikingly higher for males compared to females, particularly males of lower socioeconomic status in their 40s and 50s. Men are less likely to access help, more likely to adopt unhealthy coping mechanisms, and choose more violent mechanisms of suicide which therefore have a higher rate of completion (2).
Let’s explore the driving factors.
Driving factor 1: Gender roles
From a young age, gender roles are suggested and reinforced in society. This is quite a complex issue, and certainly not without controversy, but there are some key aspects that have damaging consequences further down the line:
- Presenting “strength” as the role of males
- Assigning emotional expression as a feminine trait (which is therefore “bad”)
- A lack of emphasis on healthy conflict resolution
Once young boys become older, the picture can complicate further as personal and professional relationships become more prevalent. Without adequate emotional development, this can spiral into unhealthy relationships and struggle with conflict, intimacy and stress. Numerous other factors (genetic predispositions, physical health problems, unhealthy coping mechanisms such as alcohol) can exacerbate these problems.
This ultimately results in many of the key “risk factors” to suicide: social isolation, infrequent/no contact with mental health services, unhealthy coping mechanisms, and so on.
What can be done?
This driving factor lends itself to early interventions, education and a proactive approach. The current education system needs to expand the social development curriculum to include honest, effective discussions on relationships, emotions, mental health and stress management. Relationship education is particularly important, as it could also be used to address the rising levels of psychosexual issues in adolescent males.
One major worry amongst parents is that this will “seed ideas” into young minds. However, we know from research that this is not the case, and in fact presenting the information alongside helpful tools, resources and resolutions may actually help (3).
Driving factor 2: Accessing help
Mental health stigma unfortunately affects everyone in the population, but we know that males are less likely to access talking therapies (2) and medical help in general. Therefore, mental health disorders in this group are either picked up much later or not at all. In the meantime, many will turn to unhealthy or unsustainable coping mechanisms, such as alcohol, which is reflected in the statistics (2).
Another issue is the self-prioritisation of medical problems. For example, consider a male attending his first GP appointment in several years. There may be several issues that have developed, certain “flags” on the system for reviews (e.g., blood pressure) and they may now be in an age bracket where other issues demand primary prevention strategies. For the patient, the feelings of sadness, guilt and anhedonia may not rank highly on the list of things to cram into such a short period.
What can be done?
There are already fantastic initiatives, such as Movember and the “RU OK?” campaign, which aim to normalise mental health conversations for males and bring these conversations into the community. This can be further developed into large scale events, such as charity sporting events which emphasise how to access help, why accessing help is so important and examples of sporting figures who have taken the steps to heal their mind.
Greater interventions in community settings represent an interesting approach as it can help to reduce the stigma within a less “clinical” environment. In addition, social prescribing initiatives can provide a direct link between the community and medical services.
Of course, the ultimate aim should be to foster a welcoming environment for those who, traditionally, do not access medical help. Advances in telemedicine and patient-driven management (such as wearable tech) may help to capture this population.
Driving factor 3: Social isolation
I’m sure you expected Covid to feature at some point!
Many of us have experienced the social isolation that comes with lockdown; weakened support networks can significantly impact on stress management, mood and resilience. Once the pandemic is over, we’ll return to regular social interactions and will probably cherish them with renewed appreciation.
For some, however, isolation is a part of life. This represents a key risk factor for suicide and has several implications, including:
- Reduced effect of community/social-based interventions
- Fewer protective factors
- Increased likelihood for unhealthy coping mechanisms
What can be done?
This is one of the trickiest areas because, by definition, those who are isolated are very difficult to reach. However, there are some key channels that can be approached, such as “rough sleepers” (of which the majority are male (2)), those who are isolated due to advanced age and those who experience greater isolation due to culture, religion, sexual orientation and other such protected characteristics.
Reaching the historically isolated populations, such as different cultures, non-English speaking populations and areas high in immigrants, is an important and yet often overlooked nuance to this. Considering the discrimination suffered by these populations, combined with cultural stigma over mental health and accessing help, it’s important that we utilise the skills of our diverse healthcare professionals to reach the communities they represent.
For many who experience social isolation, the healthcare system may actually be a rare source of interaction so this should be explored where appropriate. Depending on individual preferences, telemedicine (such as remote consultations) may actually facilitate more regular communication. Of course, for those who prefer face-to-face interactions we should try to accommodate home visits and social prescribing initiatives.
Male suicide is a complex issue which necessitates a multi-level approach. There are many risk factors that intersect, accumulate and enhance each other, and they start from early life. If we are to see improvements then the problem needs to be looked at in totality, with a united approach through education, healthcare and society. It’s promising to see increased awareness on social media channels, with entire organisations now dedicated to improving the situation. The more it is discussed, the more we can uncover key driving factors and take steps to address them. However, we must also take these pro-active steps and foster an environment of action, rather than simply raising awareness to shroud a background of rising cases.
In other words, let’s start promoting “men-tell” health!
1. Suicides in England and Wales – Office for National Statistics [Internet]. [cited 2020 Dec 27]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2019registrations