suicide in physicians

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ABSTRACT: Suicide in men has been

described as a silent epidemic:

epidemic because of its high inci-

dence and substantial contribution

to mens mortality, and silent be -

cause of a lack of public awareness,

a paucity of explanatory research,

and the reluctance of men to seek

help for suicide-related concerns. A

statistical overview demonstrates a

shockingly high rate of death by sui-

cide for men compared with women,

and a need to focus attention on pre-

vention, screening, treatment , and

service delivery. Promising lines of

research include identification of

clinical indicators specifically pre-

dictive of male suicide and explo-

ration of precipitating and predis-

posing factors that distinguish male

suicide and account for the sub-

stantial gender disparity. Only by

breaking the silencebuilding pub-

lic awareness, refining explanato-ry frameworks, implementing pre-

ventive strategies, and undertaking

researchwill we overcome this

epidemic.

Suicide in men has been des -cribed as a silent epidem-ic. 1 It has a disturbinglyhigh incidence and is a

major contributor to mens mortality.In British Columbia, suicide is oneof the top three causes of mortalityamong men aged 15 and 44. 2 Amongmen of all ages in Canada, suicideranked as the seventh leading cause of death in 2007. 3 The silence surround-ing suicide among men is also strikingand warrants comment. First, thereappears to be an overall lack of publicawareness regarding the high rates of suicide among men, especially rela-tive to other more highly publicizedthreats to mens health, such asHIV/AIDS, that account for far fewerpremature deaths among males eachyear (e.g., in 2005 45 male deaths wereattributed to AIDS in Canada in con-trast to 2857 male deaths from sui-

cide). 4,5 Second, while accumulatingempirical evidence confirms that menin Western nations consistently die bysuicide at higher rates than women 6,7

(with the pattern reversed for nonfatalsuicidal behaviors), surprisingly fewexplanatory frameworks have beendeveloped to account for this persist-ent pattern. Third, few preventiveefforts or policies specifically target-ing male suicide have been developed

or evaluated, which further contri -butes to its lack of visibility as a majorpublic health problem. When genderis addressed it is often treated as a stat-ic demographic variable as opposed toa culturally mediated social construc-tion that intersects with other diversi-ty markers such as race, sexual orien-tation, and age in highly complexways. 8,9 Finally, given mens generalreluctance to seek help for suicide-related concerns, 7 and the stigma asso-ciated with mental health problems ingeneral, it is no surprise that suicideamong men is largely invisible.

A statistical overview of the mag-nitude of the problem within a Cana-dian context reveals that suicideclaims the lives of nearly 3000 men

The silent epidemicof male suicideA lack of public awareness and too few explanatory frameworks andpreventive efforts specifically targeting male suicide have made amajor public health problem largely invisible.

Dan Bilsker, PhD, Jennifer White, EdD

Dr Bilsker is a health services researcherwith the Centre for Applied Research inMental Health and Addiction at Simon Fras-

er University, and a clinical assistant pro-fessor in the Faculty of Medicine at the Uni-versity of British Columbia. He consults tothe Mental Health Commission of Canada,with a focus on enhancing service deliveryand knowledge exchange in the Canadianmental health care system. Dr White is anassistant professor in the School of Childand Youth Care at the University of Victoria.She has been studying and practising in thefield of suicide prevention for over 20 years.This article has been peer reviewed.

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each year. Findings from a range of intellectual traditions and disciplines,including contributions from quanti-tative and qualitative research para-digms, reveal much about the conse-quences of male suicide to society.These consequences lead in turn todiscussion of prevention, screening,treatment, and service delivery issues,as well as recommendations for futureresearch.

Magnitude of the problemMen have a shockingly high rate of death by suicide compared with wo -men. Across all countries reportingthese data (except China and India)males show a suicide rate that is 3.0 to7.5 times that of women. 10 In Canada,

the male suicide rate is about threetimes that of women. 11 chartsthe age- and gender-specific incidenceof suicide in Canada, based on datafrom 2001 to 2005. Two patterns areworth noting: The male suicide rate increases fair-

ly steadily with age, peaking in thelate 40s, then falling significantlyand rising again in the 80s.

Male rates are greater than female

Figure 1

rates at all ages and substantiallygreater across most of the lifespan.

The male pattern showing a peak in suicide rate among Canadian menin their 40s and 50s is surprising inlight of multinational data showingone of two patterns: a steady increasein suicide rate with age or a peak of suicide in younger age groups. 12,13

However, a change in this suicide pat-tern may be underway, at least in

North America:Among US white men, middle agehas historically been a time of rel-atively lower risk of completedsuicide, compared with elderlymen. Yet by 2005, the suicide rateof white men aged 45 to 49 yearswas not only higher than the rate

for men aged less than 40 years butalso slightly higher than the ratefor men aged 70 to 74 yearssuicide-prevention efforts havefo cused most heavily on thegroups considered to be most atrisk: teens and young adults of

both genders as well as elderlywhite men Suicide in the middle-adult years has not been studied asextensively. 14

It is apparent that our knowledgeof mens suicide is lagging behind

changes in the age-specific incidenceof this cause of death. Until we under-stand the underlying reasons for thisrelative increase in mens suicide ratesin middle age, including potentialcohort effects, we will not be able toimplement effective preventive action.

While the analysis of suicide ratesis highly informative, some epidemi-ologists have argued that a more use-ful way to evaluate suicide impact isin terms of potential years of life lost(PYLL), which reflects both mortali-ty rate and age at which death occurs:This measure takes into account anargument that the death of a young

person involves more loss than thatof an older person. This alternativemeasure incorporates the notion thatone death is not implicitly the same asanother death. This notion is particu-larly important when one seeks toweigh the importance of suicide rela-tive to other causes of death. 15

Suicide is the second leadingcause of potential years of life lost bymen compared with women, reflect-ing both mens higher rate of suicideand the relatively young age at whichmany suicide deaths occur. In Canada,suicide accounts for about 10% of allPYLL for men; in BC, it accounts for about 7%. 11

We also need to look at suicideattempts to understand the genderdifference in suicidal behavior. Al -though men die by suicide at a higher

rate, women have a higher rate of attempting suicide. 16 This pattern isevident among youth and persists over the lifespan. 9 The ratio between sui-cide attempts, based on hospitaliza-tion data, and actual suicides for menand women in Canada, is shown in

.17 It should be noted thatthere is a spectrum of self-harm, rang-ing from acts of physical self-harmnot intended to be suicidal, to acts that

Figure 2

The silent epidemic of male suicide

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Figure 1. Median male and female age-specific suicide rates for Canada, 20012005.

Source: Statistics Canada

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reflect ambivalence about dying, toacts that reflect a clear and settled

intention to die. The broad term delib-erate self-harm (DSH) is often used inthe research literature to capture thisrange of possible actions. As onemight expect from the suicide attemptstatistics, women show much higher rates of DSH. 16

PreventionWe do not fully understand thecomplexity of suicide, including thereasons for the gender difference insuicidal behavior. This makes it par-ticularly challenging to develop effec-tive prevention programs that canaddress the high rates of suicide inmen specifically. What are the factorscontributing to mens higher rate of death by suicide; and, in particular,why do such a high proportion of malesuicide attempts end in death? Asnoted in a recent review of suicide risk screening, dramatic differences insuicide behaviors among men andwomen have drawn little attention.A better understanding of these varia-tions may have direct implications for screening and treatment strategies,and they warrant further research. 18

One line of investigation hasfocused on suicide methods. 6 A well-established finding is that men aremore likely to use suicide methods of high lethality, methods with increasedrisk of death. For example, a recent

pan-European study found that thehighly lethal methods of hanging and

firearms were more likely to be used by men. Sixty-two percent of males,versus 40% of females, used hangingor firearms in their suicidal actions. 19

Other investigators have confirmedthat compared with suicidal womenwho use firearms to shoot themselvesin the body, men are more apt to shootthemselves in the head, increasing thelikelihood of death. 20 These findingssuggest that restricting access to fire -

arms might be a way to achieve a rel-ative reduction in male suicide, andthere is some tentative support for thisas an important suicide preventionstrategy. 21-23 In contrast, it is next toimpossible to reduce access to liga-tures and suspension points common-ly used in hanging deaths since thesematerials are widely available in thecommunity. 24

From another point of view, wecould ask why men are more likely tochoose methods of high lethality. Withregard to the use of firearms, it may bethat men have more familiarity withand exposure to guns and thus aremore likely to use this method. Butwhen it comes to hanging, the pictureis far more complex. For example,

proportionally, women choose hang-ing as a method of suicide almost asfrequently as men. 6 Here in BritishColumbia for example, hanging wasthe most common method of suicidefor men and women in 2009, account-ing for 48% and 38% of suicide deathsrespectively. 2 This observation un -dermines a simplistic, dichotomousunderstanding of the role of methods(i.e., more lethal versus less lethal)

when attempting to account for the persistent gender gap in suicide.

Researchers have speculated aboutother reasons men may have for em -

ploying highly lethal means. 19,25 Theseexplanations suggest that when com-

pared with suicidal women, men whoreach the point of suicidal action are: More hopeless. 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 or dis-figured.

More unconcerned with consequenc -es because of a high risk-taking ori-entation.

More likely to have a greater capac-

ity to enact lethal self-injury.Despite some limited theoretical

and empirical support, we currentlylack strong evidence to support theseexplanations.

A study of suicide attempts in older men and women showed that menwere more intent upon dying and mov -ed more quickly and decisively fromconsidering suicide to acting upon thesuicidal ideation. The study noted,


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Figure 2. Suicide death and suicide attempt (hospitalization) rates for Canada, 1998.

Source: Langlois S, Morrison P, 2002. 17



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Our findings suggest that factors res - ponsible for the increased suicide rate

in older men operate largely duringthe suicidal crisis itself: once a depres -sed older man develops serious suici-dal intent, he tends to realize it withlittle hesitation. 26 The reasons menmove in this unhesitating way to suici-dal behavior remain to be determined.

Mens lack of social support, rela-tive to that available to women, has

been implicated as a risk factor in malesuicide. 27 An interview-based study of men who had attempted suicide sug-gested that social stressorsfamily

breakdown, overwork, employmentinsecurityoften combined with alco -hol or drug abuse, are understudiedcontributors to male suicide. 28 Some

evidence suggests that occupationalstress contributes more strongly tomale than female suicide. 29

Consistent with mens relativelylow levels of help-seeking for psy-chological difficulties, a review of help-seeking by individuals whoeventually died by suicide showedthat men had lower overall rates of contact with the formal health caresystem (including primary care and

mental health services) comparedwith women. Specifically, in the year

before suicide, an average 58% of women versus 35% of men soughtcare from a mental health practition-er. 30 In contrast, an average 78% of men who died by suicide had contactwith their primary care providerwithin the year prior to their suicide,

lending support to the role played by primary care providers in suicide pre-vention. 30

Other promising approaches in -clude community-wide interventionsaimed at changing social norms. For example, in response to low help-seeking and rising suicide ratesamong men in the early 1990s, theUS Air Force developed an innovative

population-level suicide preventionstrategy that was designed to changenorms around help-seeking, improvecommunity-wide awareness of sui-cide risks, and increase the use of lo -cal re sources. This systematic effort,which targeted the whole community,was associated with a sustained de -cline in suicide rates, providing some

preliminary support for this multi-level, early intervention approach. 31

Screening and risk formulation

There are no special protocols or in -struments recommended for screen-ing men for suicidality in primary care.The typical recommended approachfocuses on screening for depression(which is a common precursor of sui-cide) using brief questionnaires, whichare typically the same for men andwomen. 32 One might expect that menswell-established reluctance to discussrelationship or emotional difficultieswould call for more careful screeningof men by health care providers, butthere is not yet significant evidencesupporting the effectiveness of a dif-ferential approach to mens depres-sion or suicide risk.

Likewise, the evaluation of suici-dality in men typically follows thesame general protocol as that for women. 33 At the same time, certainrisk factors are more predictive of male suicide, suggesting we should

pay greater attention to these factorswhen evaluating suicidality in men.One study tracked individuals withthe diagnosis of major depression over 2 years and found certain variables to

be much more predictive of suicidalacts in men than in women: a familyhistory of suicidal behavior, previousdrug use, and early parental separa-tion. 34 Male suicides are more likelyto occur in the context of substanceuse disorders than are female suicides. 35

Men also show much higher levels of alcohol abusegiven the pervasive

effects associated with abuse of alco-hol and other drugs, it is not surprisingto find an associated increase in sui-cide. This should be a key componentin the assessment of male suicidality.Protective factors are im portant toconsider in any comprehensive sui-cide risk assessment, and evidencesuggests that protective factors maydiffer for men and women. For exam-

ple, being married appears to be a


In the year before suicide, an

average 58% of women versus

35% of men sought care from

a mental health practitioner.



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greater protective factor for men thanfor women. 16

Research possibilitiesTo date, there has not been research todetermine whether intervention for suicidality is comparably effective for men and women and whether suici-dal men should be approached withdifferent treatment modalities. A re -cent review of gender differences insuicide recommended that Researchon treatments for suicidal behavior should investigate gender differencesin response. Initiatives to develop gen-der-specific approaches may be indi-cated. Gender differences in suicidal

behavior clearly merit more researchattention to generate information thatcan guide clinical practice and pre-vention strategies in ways that will

prove most effective for preventingsuicidal behavior in both genders. 16

It is remarkable how little we havelearned about causal factors and pre-ventive strategies specifically rele-vant to male suicide. One would think that the hugely elevated rate of suicidein men compared with women wouldhave sparked a substantial investmentof resources into systematic researchand enhanced clinical practice. In -stead, the high rate of male suicide has

been treated as somehow natural andinevitable. The time has come to givethis problem high priority.

One line of research might focusupon clinical indicators that are specif-ically predictive for male suicide. 36

Recognition of suicide indicators inclinical practice is especially prob-lematic, given the disinclination of male patients to talk about emotionaldistress and their greater propensityfor impulsive behavior. The develop-ment and validation of protocols for male-appropriate suicide assessmentand intervention would greatly sup-

port health care providers in respond-ing effectively to mens suicide risk. 37

Another line of research wouldexamine the precipitating and predis-

posing factors that distinguish malesuicide and account for the substantialgender disparity in suicide mortality. 38

Why do men use more lethal methods,why do they move with less hesitationfrom thinking about suicide to imple-menting it, and why are they more

reluctant to seek help in dealing withthe stressors that contribute to sui-cide? A richer understanding of the

pathways to suicide characteristic of men will give us a stronger basis for designing programs to prevent suicidein the general male population and thesubpopulation of men with identifiedmental health problems.

Summary The epidemic of male suicide has beensilent, but it cannot remain so. Only

by breaking the silencebuilding public awareness, refining explan a-tory frameworks, implementing pre-ventive strategies, and undertakingresearchwill we overcome this epi-demic.

Competing interests

None declared.

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