Rethinking Male Suicide: A Call for a New Approach

Ever since I became a mental health nurse, I have been deeply troubled by the overwhelming rates of male suicide. Sadly, I have met many people, mostly men, both personally and professionally, who, for a variety of complex reasons, often a mixture of mental illness and social stressors, have taken their own lives. I’ve always desperately wanted to do something about this.

More than ever, terms like mental health and wellbeing are trending on social media. Mental health awareness is probably as high as it has ever been, with various awareness days and weeks that I can hardly keep track of. Yet, the number of people presenting to GPs with mental health difficulties and those taking their own lives shows no signs of abating. Call me cynical, but I think we should reconsider our current approach, as what we are doing doesn’t seem to be working effectively.

Despite my cynicism, the fact that most people know male suicide is a huge problem, that it’s a global issue, and one of the biggest killers of men under 50, particularly middle-aged men, is a good foundation for the next steps.

At the beginning of 2024, Beth Jones, a Movember ambassador, gave a talk to me and a few guys at our very first Stand Tall Sit Down. One statistic she presented blew my mind. In 2017, 91% of 40-54-year-olds who took their life, had some form of contact with frontline services in the three months prior (NCISH, 2021). Wow. This doesn’t mean these men said they were thinking of ending their lives, but they had come across a frontline service. From a professional perspective, I could in theory meet someone at risk and there is a 91% chance I’d fail to help prevent that man from killing himself. That shocks me to the core. Are we missing something?

Male suicide is a huge problem, but I think we are approaching it from the wrong angle. Recently, many organisations, charities, and awareness groups have advocated the “struggling? Speak to someone…it’s okay to talk” approach. While this remains sage advice, it might not be reaching the intended audience. This might be great for someone who is doing okay, who’s plugged into support, and has the emotional intelligence and linguistic skills to talk to someone when struggling. However, I’ve seen men in despair, and I think the “just talk” advice is going to deepen the hole they are in. We need to rethink our approach and focus on men’s strengths.

Over the years, there has been a well-documented decrease in stigma and an increase in openness to getting help, with more men reaching out and accessing therapies than ever. But suicide rates remain relatively unchanged or have even increased depending on the timeframe selected.

So, it’s my wish to ensure that when someone, whether a charity worker, a professional, a peer, friend, or family member, encourages a man to talk and get help, it should only be part of the equation.

Here are some reasons why encouraging openness should be promoted, but shouldn’t be the main strategy:

Suicide is Hard to Predict

Even after a man says he’s struggling, predicting suicide is often very difficult. Risk assessment tools are regularly used and may categorise someone’s urgency of risk correctly. However, people who are deemed low risk can still take their own lives, and those identified as high risk may never follow through. The surest tool we have is simply asking the question, ‘Are you planning to take your own life?’. Even then, this doesn’t account for acute changes in mood or rapid deterioration. Worse still, someone may really want to die and not express it.

Adding to this difficulty in predicting suicide, severe mental illness plays a significant part. Take someone with a serious mental illness like schizophrenia, schizoaffective disorder, or bipolar disorder. This person may face sudden changes in mood, lose their capacity to make informed decisions, or simply have severely impaired thinking.

External Factors

A man contemplating suicide may not see anything intrinsically wrong with himself; he may view the problem as external. Many men who take their lives don’t have a serious mental health problem or don’t see themselves as unwell. For example, crippling debt, a pending court order, significant loss of role, divorce, and significant physical health problems might lead to this thinking. Also, as hard as this sounds, I’ve known people to take their life because they made a massive mistake and felt an overwhelming amount of shame and guilt, making life seem unbearable.

When faced with significant external pressure, suicide might seem like a reasonable option to that man in that moment. It might appear to be a decision that will end his distress or struggles. If a man thinks ‘there’s nothing wrong with me…it’s everything else’, why would he seek help? As far as he is concerned, an independent and reasonable decision has been made.

Depletion of Testosterone

I have Ryan Parke (seriously check out his stuff) to thank for highlighting the evidence and science behind this. Men who kill themselves are often depleted of testosterone, depressed, angry, and facing life stressors. Low T is a significant correlating factor in depression and suicide as well as optimal wellbeing, sexual function, drive, motivation, muscle mass, and more. A man’s body with chronically  low T is not working as it should, and they will often feel they are losing in life. This combination often prevents them from opening up and expressing vulnerabilities. They may see themselves as the antithesis of what a man should be and devalue themselves alongside feeling depressed. If a man hates himself and his mind and body are not working as they should, he may get to the point that he falls into a spiral of depression and self loathing and may start to think of taking his life.

Anger as a Risk Factor

Anger is one of the biggest risk factors. Angry men often receive a worse service simply because they are hard to work with, can be nasty, abusive, and their problems may not be taken as seriously. People and services often ostracise the ‘angry man.’ Imagine being told what to do or that you’re wrong when you’re angry. You’re unlikely to seek help or admit you’re wrong. It’s also very easy to label, ignore, or put the phone down on an angry man. The angry man often isn’t taken seriously. Anger is quick, fast-acting, often completely irrational, and leads to impulsive acts.

Now, imagine this angry man is angry at himself. Just as when you are angry you might have the urge to smash your phone, punch a wall, or yell horrendous abuse at an elderly driver in a fit of road rage, an angry man may internalise this anger. He may hate himself and that anger becomes directed at himself. In that acute episode of anger, where your evolutionary hardware is doing everything it can to get you to act on this anger, it can be a deadly combination. Sadly, fatally punishing yourself doesn’t seem too much of a stretch. This man isn’t expressing his vulnerability and opening up to get help. After all, when you’re angry, you’re right, and everyone else is wrong.

Lack of Disclosure

Many people who kill themselves don’t actually tell anyone or don’t want to tell anyone, despite the support around them. When these men get help, it’s not the man talking, but the support network catching them. Unfortunately, this lack of disclosure happens alot and for many reasons. I can’t say how common this is, but intuitively, from the people I’ve known who’ve taken their life, a sizable portion were asked the question about ending their life, but never expressed any concerns. They probably kept it to themselves and had made a decision.

Substance Abuse

I dont have the evidence at hand to back this up, but it’s there. I think substance abuse is probably one of the biggest factors in suicide. And statistically, it’s us men who are more likely to struggle with addiction.

A man who is abusing drugs probably has a few stressors in his life anyway, and using excessive drugs and alcohol will lead to massive see-sawing of chemicals and neurotransmitters. This will cause huge swings in mood and thinking, atop underlying depression or life stressors. For example, take a man in his 20s, who has gone out on a few benders, using coke, speed, alcohol, experiencing sleep deprivation, and facing reasonable worries in life like a partner, money, and low self-esteem. These reasonable worries could become blown out of proportion during a comedown, disrupting the delicate balance of neurotransmitters and hormones. Acute changes in mood and thinking can lead to sudden impulsive attempts on life. Furthermore, some drugs and prescribed medications can cause suicidality as a side effect. We’ve got to check in with men about their substance use, particularly if there is already a mental health illness present.

Difficulty Expressing Feelings

Lastly, and one of the most glaringly obvious points, yet often overlooked by mental health awareness campaigns or charities, men, on average, aren’t as good at expressing feelings and opening up as their female counterparts. If I were blunt, it’s like these awareness posts and campaigns are treating men as defective women and think ‘if only men could be more like women, they’d be better’. This advice can make a man feel broken; ‘I talk, and I don’t feel better…I can’t express myself, there must be something wrong’. The only people I’ve seen to not express the ‘just open up’ view are usually experienced staunch men’s wellbeing advocates. These advocates know full well that men’s needs will generally differ from women in expressing themselves.

Men also often lack the linguistic and emotional intelligence skills and don’t always benefit from talking about their problems as much as women. Studies like Denneson et al (2021), demonstrated that post suicide attempt support looks little different from men compared to woman. Women benefit from support in talking about it. Men benefit from support where they have some sort of shared goal and don’t talk about it. Furthermore, men tend to value independence and decision-making, and talking is sometimes against these values. Going against these values can make things a lot harder.

If a man is struggling and able to express himself and get help, this is great. But it can be hard, and for some men, impossible. If opening up and being vulnerable goes against his values or what he feels in his heart of hearts, and if it just isn’t in his nature or he isn’t himself, he isn’t going to say a peep. The only way you are going to get men to talk is for them to be well in themselves and connected to a meaningful community. Then, expressing themselves and having that mutual peer support will be a protective factor. He can then start to adjust his values and learn that it’s okay to be vulnerable from time to time. It’s simply not as easy as a quick; ‘speak to someone and get help’ post. I wish it was.

 

Closing remarks

I don’t have a perfect answer but as well as encouraging speaking up.  We should be encouraging men to be part of communities and groups that have nothing to do with mental health or talking. We should be instilling that little bit of self-development and health promotion. We should be taking an active part in extending invitations and connections with men in our lives. For me fundamentally, men who value their lives, feel useful, have connections and community and who’s bodies are working as they should are far less likely to end their life. This is what we need to aim for. This should be what all the men’s mental health awareness should be about

References

Denneson, L. M., Tompkins, K. J., et al. (2021). Gender differences in recovery needs after a suicide attempt: A national qualitative study of US military veterans. Medical Care, 59(Suppl 2), S116–S121. https://doi.org/10.1097/MLR.0000000000001504

National Confidential Inquiry into Suicide and Safety in Mental Health. (2021). Annual Report 2021. HQIP. https://www.hqip.org.uk/wp-content/uploads/2021/05/NCISH-Annual-Report-2021.pdf