Suicide in men: the time is ripe for active scientific investigations.

Abstract

Suicide in men is a really major social and medical problem. Men have a much larger rate of completed suicide in comparison with women 1-3. Worldwide, men commit suicides three to eight times more frequently than women 1-3. The gender differences in suicide rates are especially significant in some Eastern European countries such as Hungary, Latvia, Lithuania, Poland, and Slovakia 3. In 2014, in the United States, the age-adjusted suicide rate for males (20.7 per 100 000) was more than three times that for females (5.8 per 100 000) 4. Suicide is a silent killer of a large number of middle-aged American men. According to the U.S. Centers for Disease Control and Prevention, deaths from suicide in the United States increased 24 per cent from 1999 to 2014 4. However, suicide rates for men aged 45 to 64 jumped by 43 per cent from 1999 to 2014, increasing from 20.8 per 100 000 in 1999 to 29.7 per 100 000 in 2014. An important study published in this issue of the Journal shows that suicide attempts are associated with reduced longevity 5. A research group led by Jussi Jokinen examined mortality among suicide attempters in comparison with the general population. The authors observed that the life expectancy was reduced by 18 years for 20-year-old men and by 11 years for 20-year-old women who made their first suicide attempt during the study period. The life expectancy for 50-year-old men and women was reduced by 10 and 8 years respectively. Most suicide attempters died of physical illnesses and not by suicide. This study indicates that men who make suicide attempts are not only at high risk for dying by suicide but also at an elevated risk to die as a result of medical conditions. Efforts at suicide prevention are hamstrung by the shortage of knowledge about the reasons for the increased rate of suicide among men and its underlying psychological and neurobiological basis. Different theories have been proposed to explain high suicide rates in men 1, 2. There is likely a convergence of various factors that make men vulnerable to suicide. A discussion of all theories and hypotheses related to suicidality in men is beyond the scope of this article. Four ideas related to suicidal behaviour in men will be briefly discussed in this article: lack of help-seeking among men who need psychiatric help; the impact of socioeconomic issues on men; the effect of divorce and parental alienation; and the role of testosterone. The vulnerability of many men to suicide may be related to their relative unwillingness to get help when they are depressed, anxious, or distressed. There is a substantial discrepancy between help-seeking in men and need for help with regard to both psychological and physical problems 1, 2. Apparently, multiple psychosocial and neurobiological factors contribute to an underestimation and denial of symptoms by men. There is another question, however. Is good psychiatric help available to men who need help? It has been observed that some mental and non-mental health clinicians sometimes treat distressed, depressed, anxious, and/or suicidal men in an incompetent and unempathic manner 2. Such clinicians, at times, do not detect mood, anxiety, psychotic disorders, and suicide risk in men, especially, when men have a history of impulsive-aggressive behaviour and/or substance use disorders. Men who have access to well-educated and well-trained psychiatrists may get superior professional help. Do many men around the world have access to superior psychiatrists? Probably, a lot of men have access to only low-quality mental health services or no access to professional help at all. It has been proposed that suicidal behaviour in men may be related to socioeconomic factors such as income and social status 1, 2. Mens’ vulnerability to suicide may be heightened during periods of economic difficulties because of anticipations that men should support themselves and their families. The failure to be the family provider may strongly stress men. Also, unemployment and poverty are often associated with family problems, depression, anxiety, hopelessness, and helplessness which all may lead to suicidal behaviour. An important research report published in this issue of the Journal suggests that academic performance in school and childhood IQ are predictors of future suicidal behaviour 6. A research group led by Alma Sörberg Wallin examined the association between school performance and suicidal behaviour up to middle age. The authors also investigated whether the association between academic performance and suicide attempt is related to a general cognitive ability, as measured with an IQ-type test. Researchers observed that poor academic performance in school, at age 16, was a strong predictor of suicide attempt past young adulthood. The association between IQ and suicide attempt was mediated by academic performance. The results of this study are probably relevant to the issue of suicide in men. Poor academic performance in secondary school reduces future opportunities for professional education and training. It is more difficult to successfully find and maintain a job for men with limited education and professional training than for well-educated professionals. Therefore, poorly educated unemployed or underemployed men are at elevated suicide risk. Divorce and parental alienation may lead to stress-related disorders and suicide in men 7, 8. Divorced and separated men are nearly 2.4 times more likely to kill themselves than married men 8. Family breakdown leads to many difficulties for men including the possibility of parental alienation. Parental alienation is usually defined as a mental state in which a child, usually one whose parents are engaged in a high-conflict separation or divorce, allies himself firmly with one parent (the preferred parent) and refuses a relationship with the other parent (the alienated parent) without legitimate justification 7. Fathers who have lost some or all contact with their children for a long time following separation or divorce may become depressed and suicidal. Multiple research reports and theoretical papers suggest that testosterone may be involved in the pathophysiology of suicidal behaviour in men 9. However, the role of testosterone in the neurobiology of suicide remains unclear. A relation between testosterone and the neurobiology of suicidal behaviour may be related to (i) a direct effect of testosterone on suicidal behaviour via certain brain mechanisms; and/or (ii) a testosterone effect on aggression and, consequently, suicidal behaviour; and/or (iii) a testosterone effect on mood and, consequently, suicidal behaviour; and/or (iv) a testosterone effect on cognition and, consequently, suicidal behaviour. Possibly, low testosterone levels are associated with suicidal behaviour in older men while high testosterone levels are related to suicidal behaviour in adolescents and young adults. It is of interest to note that one of our studies has shown that blood testosterone levels may be associated with suicidal behaviour in women 10. We have observed that higher baseline testosterone levels predicted suicide attempts during the follow-up period up to 2.5 years in women with bipolar disorder. Suicide in men is a vital issue in men's health care, as it has reached epidemic proportions. This places an ethical responsibility on researchers and clinicians to try to understand this epidemic and prevent these tragedies. We need to know more about why this is happening. We have a moral obligation to help men and the women and children who love them. Research studies on the psychobiology of suicidal behaviour in men are definitely merited. Note: Leo Sher, M.D., is Chair of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force on Men's Mental Health.