Depression and Suicide in Men

O

ver the last decade, the rate for diagnosed depression has increased ^[1-4] and is one of the leading causes of disability worldwide ^[5.6]. Studies have confirmed that women are twice more likely to be diagnosed with depression than their male counterparts ^[7,8]. Severe depression is a known risk factor for suicide, yet despite the low reported rates of depression among men, suicide rates are up to four times higher in men than women ^[8-10]. Indeed, suicide is one of the leading causes of death for men in all age groups ^[11,12]. The discordant relationship between men’s low rates of formally diagnosed depression and high suicide rates ^[13-17] is in part due to men’s alignment to traditional masculine characteristics such as self-reliance and stoicism, which discursively shape men’s reluctance to seek mental health care services ^[18]. The primary objective of our research is to understand the connections between masculinities, depression and suicide, as a means to developing men-centered interventions.

Methodology

Our men’s depression studies focus on three sub-groups; college men, men in middle age and elderly men. The studies are conceptually linked by focusing on masculinities. We have interviewed more than 100 men throughout British Columbia, Canada, who were formally diagnosed or self-identified as having depression. Prior to the individual interviews, depression is measured using the 21-item Beck Depression Inventory, second edition ^[19] and brief demographic data is also collected. With the overarching research question ‘How does masculinity shape men’s depression and suicide?’ we have begun to analyze data from each of the sub-studies. Originally, we were focused on men’s depression, but early on in the data collection phase, we were struck by the details participants shared about suicide. For example, participants detailed their strategies for dealing with suicide and suicidal thoughts, and the findings that follow are drawn from two sub-studies of middle aged men and older men.

Men of middle age

This sub-study provided insights on how masculine roles, identities and relations mediated depression-related suicide thoughts in a cohort of 38 men, ranging in age from 24 to 50 years-old. Constant comparative analyses yielded the core category of Reconciling despair in which men responded to severe depression and suicidal thoughts by following two pathways (See figure 1). To counter suicide actions, connecting with family, peers and health care professionals and/or drawing on religious and moral beliefs were important interim steps for quelling thoughts about suicide and eventually dislocating depression from self-harm. This pathway revealed how connecting with family through masculine protector and father roles enabled men to avoid suicide while positioning help-seeking as a wise, rational action in re-establishing self-control. The other pathway, contemplating escape, rendered men socially isolated and the overuse of alcohol and other drugs were often employed to relieve emotional, mental and physical pain. Rather than respite, these risky practices were the gateway to men’s heightened vulnerability for nonfatal suicidal behavior. Men on this pathway embodied solitary and/or risk taker identities synonymous with masculine ideals but juxtaposed nonfatal suicidal behaviors as feminine terrain. The findings drawn from this study have significant relevance for clinicians, researchers and policymakers who are dedicated to advancing men’s mental health and suicide prevention.

Figure 1. Conceptual model detailing men’s countering and contemplating of suicide.

Practice implications

With regard to primary prevention, public health policy needs to make visible the diverse ways in which men construct ideals and produce masculinities to decrease men’s risk for suicide. It is clear that masculine practices (some of which are idealized) can actually mitigate suicide risk. This was evidenced by participants’ ability to counter suicide actions by pragmatically repackaging masculinity to meaningfully connect and confide in others as the conduit to effective self-management. By endorsing diversity in masculinities within a broad range of settings alternate scripts for depression and suicide can be made available to men. Similar to the ‘Real Men, Real Depression’ ^[20] campaign, which linked courage to help-seeking for men’s depression, approaches that highlight emotional fitness and mental strength, within a positive and non-stigmatizing framework; and skill development courses that aim to broaden men’s self-monitoring and management (e.g., ways to ask for help, recognizing emotions, and mechanisms for emotional management) can appeal to diverse groups of men.

Older men

In this sub-study we conducted individual interviews with 22 men (55-79 years-old) who self-identified or were formally diagnosed with depression to better understand the linkages between masculinity, depression and suicide among older men. We found that cumulative losses around social bonds were central to men’s depression and suicidal thoughts. Prominent were self-assessments of failed provider and/or protector roles, judgments that led men to ruminate on their shortcomings amid recognizing their older age as limiting opportunities for redemption. Stigma featured as a barrier for men acting on their suicidal thoughts. Specifically, guilt about the stigma and pain their suicide would invoke on bereaved family and friends was a strong deterrent for older men’s self-harm.

Practice Implications

Much of the literature suggests adjustments to professional mental health services as key to improving the well-being of older men who experience depression [21-29]. In this regard, clinicians might include questions about work and family as well as directly asking about older men’s thoughts about self-harm or suicide. In addition, bringing targeted community based programs to the attention of older men, as previously suggested by Kravitz et al ^[27] and Williamson ^[30] can effectively connect men with other men, and reconnect them with work. For example, the Australian men’s sheds initiative  and the UK’s men in sheds program have successfully attracted older men to workshop-type spaces in community settings to provide opportunities for regular hands-on activity by groups deliberately and mainly comprising men. The full findings drawn from this sub study will be published in 2011.

Conclusion

Understanding the diversity and complexity of masculinities in men’s depression and suicide is an essential step toward mobilizing effective suicide prevention strategies. Men do not comprise a single or unitary group. From this standpoint, men-centered suicide prevention strategies that are responsive to specific sub-groups of men will be especially beneficial. Programs that remind men about their important family and social roles, while encouraging them to redefine unhealthy masculine practices, such as denying illness and resisting professional help, can significantly reduce depression and suicide. Often times a supportive partner is central to the successful management of men’s depression; however the limits of a women’s resilience and care giving must also be acknowledged. In this regard, making available opportunities for couples to assess their relationship dynamics within a broad range of gender relations might also support couples connectedness and life quality amid the challenges that routinely accompany men’s depression.

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