The Silent Killer

This week’s blog post is by Fahmida, our 5th year rep, who has managed to find time in this stressful period of every med student's life to write on International Men’s Day

CW: suicide, mental illness

Happy International Men’s Day! Apologies in advance as this blog is long and not exactly a cheerful one. I thought, in keeping with the theme of International Men’s Day and psychiatry, I would pay homage to men who have sadly died by suicide. And so, I’ve read around male suicide and offered my two cents here. Mental illness and suicide seem to be highly sensitive, almost taboo topics. I think we, both men and women, need to push past that initial stage of embarrassment, or whatever it is we feel, and be real and open with one another. Have conversations. How do we really feel? Are we coping? What do we need? I believe that having a discussion with one another about our mental health is a step in the right direction and may even prevent deaths. We talk about physical illness so openly, why not mental illness?

Statistics Let’s talk numbers. I found that depending on the source and country I look at, there are various different information on trends of suicide rates and age brackets/sex most at risk. The fact of the matter is though, a life lost to suicide is a life too many. To put things into perspective, roughly 800,000 people die by suicide each year and it is thought that most of these deaths are young men. The diagram below is taken from WHO’s Suicide in the World: Global Health Estimates document and shows the top three causes of death for people aged 15-29 in 2016. For men, the most common causes of death were road injury, interpersonal violence, and suicide.

The next diagram is taken from the Samaritan’s Suicide Statistics Report which collates data for the UK. The suicide rates for males aged 20-24 years remains consistently high year after year at around 17 per 100,000. This is more than three times that of suicide rates for females of the same age. What causes this disparity is discussed further on.

Some more facts and figures: • In 2018, 6507 suicides were registered in the UK and 352 occurred in the Republic of Ireland. • The highest suicide rate in the UK is in Northern Ireland in men aged 25-29. • The highest suicide rate in England is among men aged 45-49. • The highest suicide rate in Wales is among men aged 40-44. • The highest suicide rate in Scotland is among men aged 35-44. • Some sources suggest that suicide rates increase fairly steadily with age, peaking in the late 40s then falling significantly before rising again in the 80s. • Women are more likely to attempt suicide, but men are more likely to die from suicide. This is due to male methods of suicide being more violent. Hanging, using firearms, jumping off bridges etc are more likely to lead to completed suicide.

The big question – why? Why do more men die from suicide? It could be due to innate differences, how they are conditioned from birth, or both. Women are able to communicate with one another and talk about their problems, whereas men find it difficult to reach out and are taught to be tough. I think an important factor to consider is traditional gender roles which discourage boys from crying or expressing emotion, as this is seen as weak. It’s strange how displaying weakness is seen as a negative characteristic… I personally think there is a strength in showing vulnerability. On a separate note, depression may be underdiagnosed in men as they are less likely to disclose how they are feeling to their doctor, and so they don’t get treated. Dangerously, instead of seeking help, men may choose to self-medicate with alcohol and drugs which compounds the issue of suicide.

Other factors which may contribute to mental illness and suicide: • Social isolation • Divorce or relationship breakdown • History of sexual or physical abuse • Imprisonment • Being bullied • Loss of a loved one • Mental or physical illness • Academic pressures • Self-harm • Family issues • Unemployment • Financial worries • Being discriminated against • Adverse childhood experiences • Neglect • Homelessness

Solutions Possible solutions to decreasing the number of deaths? Suicide is definitely preventable but there are no straightforward, quick fixes for an issue so complex. From a national perspective, suicide prevention strategies rely on the timely registration of deaths and regular monitoring of suicide trends in order to be effective. It is important for countries to collect data and use disaggregated rates by sex, age, and method. Doing so provides understanding of the scope of the problem so that interventions can be tailored to specific populations.

Various programmes, policies and non-profits are gaining traction. In Australia for example, suicide prevention programmes are trying to shift the cultural paradigm. One initiative is “RU OK?” day which encourages people to start a conversation with those who are struggling. The “shoulder to shoulder” principle encourages men to talk while otherwise occupied, for instance when watching football or going for a bike ride. Calm’s campaign Project 84 – so named to represent the 84 men who die weekly by suicide in the UK – stresses the devastation left behind when a man takes his own life.

In 2012 the Government developed a strategy to reduce the suicide rate and improve support for those affected by suicide. It discusses the importance of GPs in preventing suicide, as GPs are often the first people seen by those experiencing distress.

Mental illness is mainly managed in primary care, though it is unrecognised in many patients, so there needs to be more awareness amongst general practice staff. Suicide has also been associated with physical illness. Many people living with a long term physical condition have depression which is undiagnosed. Screening high risk groups like these may identify those with mental illness so they can be appropriately managed.

Times are tough though, and services stretched beyond their limits. A practical solution is to make suicide more difficult to complete. A study found that after barriers were installed on the Clifton suspension bridge in Bristol, the number of deaths from jumping off the bridge halved. Other preventative measures in place include reducing accessibility to firearms, banning ligatures in prisons and restricting purchases of analgesics in shops. Media coverage is also key to suicide prevention by educating the public on mental disorders as well as ways of identifying those at risk. Since not all men are in contact with health services, friends, family, school staff, care givers etc should be equipped with the tools needed to identify risk.

Finally, at an individual level, the safest bet is to be kind and look out for one another. Remember to check in on your friends, family, and colleagues.

Below are some links for anyone who is struggling or affected by this topic:

Samaritans – for everyone Call 116 123 Email jo@samaritans.org

Campaign Against Living Miserably (CALM) – for men Call 0800 58 58 58 – 5pm to midnight every day Visit the webchat page

Papyrus – for people under 35 Call 0800 068 41 41 – 9am to midnight every day Text 07860 039967 Email pat@papyrus-uk.org

https://www.mind.org.uk/.../suicidal.../useful-contacts/ have a great list of contacts

If it is an emergency: Call a GP – ask for an emergency appointment Call 111 out of hours – they will help you find the support and help you need Contact your mental health crisis team – if you have one

References 1. Schumacher H. Why more men than women die by suicide [Internet]. Bbc.com. 2019 [cited 19 November 2020]. Available from: https://www.bbc.com/.../20190313-why-more-men-kill... 2. Kennard J. Why More Men Are Taking Their Own Lives [Internet]. Verywell Mind. 2020 [cited 19 November 2020]. Available from: https://www.verywellmind.com/men-and-suicide-2328492 3. Bilsker D, White J. The silent epidemic of male suicide. British Columbia Medical Journal [Internet]. 2011 [cited 19 November 2020];53(10). Available from: https://www.researchgate.net/.../The-silent-epidemic-of... 4. Suicide in the World: Global Health Estimates. WHO; 2019. 5. Suicide data [Internet]. Who.int. 2020 [cited 19 November 2020]. Available from: https://www.who.int/.../mental-health-and.../suicide-data 6. Suicide Statistics Report [Internet]. Samaritans; 2019 [cited 19 November 2020]. Available from: https://media.samaritans.org/.../SamaritansSuicideStatsRe... 7. Hardy S. The role of primary care in preventing male suicide | Practice Nursing [Internet]. Magonlinelibrary.com. 2019 [cited 19 November 2020]. Available from: https://www.magonlinelibrary.com/.../pnur.2019.30.11.538 8. Why Are So Many Men In Britain Killing Themselves? [Internet]. Esquire. 2017 [cited 19 November 2020]. Available from: https://www.esquire.com/.../britain-male-suicide-crisis/ 9. Schwartz-Lifshitz M, Zalsman G, Giner L, A. Oquendo M. Can We Really Prevent Suicide?. [Internet]. 2012 [cited 19 November 2020];. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492539/....