Features

On the edge

08 November 2018

The suicide rate in the UK may be going down, but three times more men than women took their own life last year. Journalist Sarah Campbell asks what’s going on and how you can make a difference.

Last year, more than 5800 people died by suicide in the UK – three-quarters of those were male. The highest suicide rate overall was in Scotland, the lowest was in England. (For detail on Northern Ireland, see page 41). Overall, the rate is going down: the 2017 figures for male suicide are among the lowest since records began in 1981 at 15.5 deaths per 100,000 (ONS, 2018a).

This is encouraging, but the figures are still stark. Suicide is the biggest killer of males aged under 45 in the UK (CALM, 2018). Looking specifically at young people, suicide remains the leading cause of death for five- to 19-year-olds in England and Wales (ONS, 2018b), for boys and girls – for more details, see page 43. Suicide figures may not even represent the true picture: reaching verdicts on civil, not criminal, standards would likely produce a higher number of people taking their own lives.

Suicide prevention charities have long been campaigning for the standard of proof for coroners’ rulings of suicide to be lowered. Until very recently, a coroner had to conclude beyond reasonable doubt that a person died by suicide. But this is about to change, following a High Court ruling that lowered the standard of proof for a suicide verdict in England and Wales, so the coroner can now reach a conclusion on the balance of probabilities (Geering, 2018).

This move is significant not only to increase the accuracy of the reporting of suicides, but as part of the movement to de-stigmatise suicide. Taking your own life has not been a criminal offence since 1961, and yet we still – although suicide prevention campaigners advise against it – talk about ‘committing’ suicide.

Society’s aversion to the idea of suicide is one of the many complexities to analysing the statistics. There is no single answer to why male suicide rates are so much higher than female, or why rates in Scotland are higher than in England, although a research project announced earlier this year by the University of Glasgow into male suicide triggers may start to shed some light (see Lessons from the lab below).

The reasons behind and events leading up to each suicide are unique and complex, but poverty and inequality are linked to suicide. The Dying from inequality report sees suicide as a multi-faceted problem of psychological, social and economic factors. It foregrounds causes such as unemployment, debt, a lack of agency, and health-harming behaviours including alcohol and drugs (Samaritans, 2017). And another Samaritans report pointed out that it was those middle-aged men in the lowest social class that were most at risk of suicide – up to 10 times more likely than those from higher classes and more affluent areas (Wyllie et al, 2012).

 

Expressing emotion

The perceived stigma attached to simply talking about feeling suicidal seems to affect men. Kelly Thorpe, head of helpline services at Papyrus UK, a charity dedicated to the prevention of young suicide, notes that more young women than men call their support and advice line. This could indicate that part of the reason fewer women take their own lives than men is that women are more likely to talk about it when they’re feeling suicidal.

‘As communities, we’ve done a great job of getting the message out there that it’s okay for young men to express emotions,’ Kelly says. ‘In those campaigns we’ve put pressure on young men to speak out for themselves and seek help. We should perhaps promote the fact that people around them need to look out for them too.’

Anonymity can be key to helping men start out on a journey to getting help

Taking positive action to seek help when experiencing suicidal thoughts is a difficult step for some men, says Jim Pollard of the Men’s Health Forum. ‘Take going to the GP,’ he says. ‘You have to go there in person, explain your problems, then be referred to someone else. Theoretically, you can refer yourself to mental health services through the Improving Access to Psychological Therapies programme, but I reckon very few people know that.’

He says that anonymity can be the key to helping men start out on a journey towards getting help if they’re feeling suicidal. In 2016, the Men’s Health Forum ran an anonymous online chat and email service for a year called Beat Stress. ‘One of the important things with that was that it could give men permission to go and get help. It’d make them think: “I won’t be wasting the doctor’s time”,’ Jim says.

The Beat Stress service did not advertise that it was staffed by mental health professionals. Researchers had looked into the language that men use to talk about mental health and advised that less medicalised terms such as ‘stress team’ were more likely to attract and engage men (Stein, 2018).

‘Something else we found is that young men and older men use different language,’ Jim says. ‘Young men are more comfortable using language that you might consider more feminine (for example, they might say they’re “feeling vulnerable”). Older men tend to be “stressed” or “pissed off”. They prefer to talk about something that happens to you rather than within you – something external causing stress in their life. But for younger guys, maybe the language is merging a bit, maybe attitudes around what’s perceived as male and female are more fluid. Which is a good thing.’

Infographic

Men’s place in society

As well as the language we use to consciously talk about mental health, it’s also worth being mindful of the language we use almost without thinking that reflects society’s perception of masculinity.

‘Society has this view of men: we tend to use language like “man up”. That affects men a lot,’ says Evri Anagnostara, a modern matron at East London NHS Foundation Trust and chair of the Mental Health Nurses Association. ‘In addition, when people experience mental health problems they often feel very isolated and lonely and can’t see a way out of their problems. So these pressures together may mean men feel distressed and try to find a solution to their problems themselves. And for some, suicide is the way to solve that problem.’

While mental health problems and suicide are often related, it’s important to remember that many people who take their own lives might be struggling with an event or life change, rather than an existing ongoing mental health issue. Take the birth of a baby. ‘We often forget the dad,’ Evri says. ‘Even at that moment of happiness they can feel isolated, left out of the equation.’ Plus they may be feeling pressures related to the stereotypical role of men in society, that they need to provide financially for their growing family, for example.

Kelly agrees that significant life events and changes can be contributory factors for young men who become vulnerable to suicidal thoughts. ‘It’s the key transitions: finishing school, going to work or university, the educational pressures,’ she says. ‘Social media plays a huge part in regards to living up to what is a “perfect young man”. It feeds into the fear of failure, of not being successful in relationships, education, work – feeling weak that they can’t cope and should be able to.’ Exams and bullying are other vulnerable times for young people listed by Papyrus UK on the website. Add into this the likelihood of having their first sexual experiences around 15 to 19 and the pressure around that, and it becomes clear that this can be a difficult time for a young man to navigate.

‘Stereotypically, young women talk more,’ Kelly adds. ‘It’s safer for them to express emotions, perhaps. Women are not going to get judged when we cry when a relationship breaks down. For a young man, that would probably not be acceptable behaviour.’

For older men, it is likely to be even less acceptable behaviour. Suicide rates are highest among men aged 45 to 49 (see Mid-life crisis? Below). Oliver Chantler, public affairs and campaigns manager at Samaritans, says: ‘Relationship breakdown often happens in middle age. There’s some research around how middle-aged men can be isolated in that they only have a partner to speak to, so if that partner leaves, things can get difficult for them.’ He also points out that, for this generation, changing social conceptions of masculinity and the decline of male-dominated industries such as manufacturing might leave them feeling like they don’t fit in anywhere in society.


Mid-life crisis?

Why are men between 45 and 49 at the greatest risk of suicide?

  • Psychological and personality factors
    Mental health problems play a part in many suicides. Added to this, self-criticism, brooding, and reduced social problem-solving ability can interact with deprivation and trigger events such as the end of a relationship or unemployment to increase suicide risk.  
  • Masculinities
    Men, especially older men, can prize power, control and invincibility and feel shame and defeat if they do not live up to this ‘gold standard’. Men are more likely to use drugs or alcohol in tough times.
  • Relationship breakdown
    Men rely more on partners for emotional support and suffer its loss acutely. Perceiving a loss of honour can lead to impulsive reactions.
  • Emotional lives and social disconnectedness
    Older men particularly can lack social and emotional skills and be reluctant to talk through problems.  
  • Middle age
    The ‘prime of life’ can actually be a time of problems with relationships and employment, and the possibility of change is more limited.
  • Socioeconomic position
    Those in lower positions of job, class, education, income or housing are more at risk of suicide, even allowing for mental health problems.

 

A note on Northern Ireland

The most up-to-date Northern Ireland figures (from 2016) reveal a similar proportion of men taking their own lives as the rest of the UK (NISRA, 2017).

While the ONS reported data for the UK as a whole for their report on suicides, it did not report the latest 2017 numbers of deaths and rates for Northern Ireland; these will be published later this year on the Northern Ireland Research and Statistic Agency website (ONS, 2018a).

 

 


 

Space for conversation

However, as evidenced by the slowly declining suicides in the UK, it is possible to stop at least some of them happening. Evri says: ‘Suicide should not happen. Of course there are always going to be people that for whatever reason have made up their mind that suicide is the best solution, but I don’t want to accept that. It’s never inevitable as far as we are concerned professionally.’

Many frontline NHS staff, including community practitioners, receive suicide prevention training as part of their trust’s suicide prevention strategy, but this can vary according to geography and funding and it isn’t necessarily followed up in CPD. While training is valuable, Oliver has a further call to make of employers. ‘Frontline staff are caring and empathetic. That’s why they chose those vocations,’ he says. ‘One thing we really need is for employers – and for the Department of Health and Social Care – to ensure that staff have space and resource to be empathetic in their roles, so they can have those conversations with people at risk of suicide.’

Staff need that time and space because those conversations are not easy and can take their toll on anyone, healthcare professional or not. ‘It’s hard to ask someone: “Are you feeling suicidal?”’ says Kelly. ‘My message is if there’s any change in someone’s behaviour, especially following significant change or loss, and if that’s making you feel uncomfortable that gives you permission to ask. As a healthcare professional, you do have things to look after you – procedures, supervision, support and so on – but the more emotionally attached you are, the more difficult it gets.’

She reassures that it’s hard to get the conversation wrong and it’s unlikely that just saying the word ‘suicide’ is going to plant the idea in someone’s head or make things any worse for someone you suspect is already having those thoughts. ‘The only thing I would say is be careful of talking openly about method and don’t do a checklist: “Are you planning this, or this, or this?” If someone’s suicidal you need to ask what their plan is so you can keep them safe, but don’t give them other options.’

For people in immediate danger of suicide, A&E is the way to go. For less acute cases, GPs can help people to access the appropriate services. As Jim pointed out earlier, for many men, being given ‘permission’ to bother the doctor by a disinterested or anonymous third party can be a helpful first step. The other side of the suicide prevention coin is national strategy.

It’s daily interactions that can make a difference to those at risk of suicide


Finding answers in India

India has one of the highest rates of suicide in the world (WHO, 2018). Almost a quarter of the world’s male suicides take place there (Dandona et al, 2018).

Steve Jones, a former mental health nurse and now a researcher at Edge Hill University’s Faculty of Health and Social Care, has spent time in southern India conducting research into hospital staff attitudes towards people who attempt suicide. He is hoping to find helpful comparative factors between India and the UK that could help improve the care of people who have survived a suicide attempt.

‘The social problems behind people’s attempts to kill themselves are similar to those in the UK but more stark and obvious in India,’ Steve says.

‘We’re only talking about £20 of debt but in relative terms that can be a huge burden. Other issues were very similar: employment, self-worth, stigma, self-esteem.’  

The differences are also numerous, though. In some intensive care units that Steve visited in India, up to half of the beds were taken by people who had tried to kill themselves, usually by ingesting pesticides. ‘Then you’ll have the bill for your treatment, which can lead to more debt – which might have been one of the reasons behind the original attempt,’ Steve says.

So it’s clear that Steve isn’t comparing exactly like for like, but where UK frontline staff can take lessons is around how people who have survived a suicide attempt are spoken to and treated, and the training of staff.

As part of his research, Jones says he trained 250 general hospital staff in the use of a global mental health assessment tool, and the results were encouraging.

‘We’re still auditing it every six months, but we’ve seen a 100% increase in referrals to psychiatry,’ he says. ‘It shows that even in these wards, where you have 30 patients and three members of staff, the right short assessment can open up a dialogue between general nurses and mental health services.’


Lessons from the lab

Rory O’Connor, professor of health psychology at the University of Glasgow’s Suicidal Behaviour Research Laboratory, has studied suicide for 20 years. He offers insight into the latest figures and practical lessons for CPs.

‘When I started working in this area, the highest-risk group was young men. Now it’s middle-aged men,’ he says. ‘It’s as if men who were in their 20s in the 1980s are carrying the risk with them. It’s to do partly with changing norms and expectations of men. But surprisingly, even though we know a lot about risk factors such as mental illness, alcohol problems, unemployment and trauma, we still don’t know enough about the big difference between male and female suicide rates.’

As for why rates in Scotland are higher than England and Wales, he says this has been the case only since the 1950s. ‘It’s something to do with the proportion of disadvantage,’ he says. ‘Deprivation is a key predictor of suicide. There’s also social isolation in rural areas, which perhaps prevents people accessing services. Also our relationship with alcohol is different from that in England, and alcohol is often a factor in suicidal behaviour.’

Rory’s research team takes multiple approaches to the complex subject of suicidal behaviour: interviews, population studies, visiting people who have attempted suicide in hospital, and even bringing people with a history of suicidal behaviour into the lab to put them under stressful conditions (in a safe, consensual way).

Understanding suicide

In terms of understanding what 
might lead an individual to attempt suicide, research has made headway. Rory has developed a model of the suicidal mind that helps to understand how some people develop suicidal thoughts, and then convert those thoughts into action. (Find out more here)

The lab has more than 30 research projects on the go, ranging from studies into the relationship between responding to stress and suicide risk to studying whether people who are more likely to take their own lives have a higher pain threshold.

Your practice

What lessons from the lab’s research might be most applicable to community practitioners? ‘Statistically, there’s evidence that if you know someone who’s died by suicide, you’re more at risk yourself of becoming suicidal,’ he says. ‘That’s not to be alarmist but you need to be vigilant for example in a school or community where there’s been a suicide.’ (Find resources for those who have been affected by a suicide, including children at bit.ly/bereavement_support)

He stresses the need to take self-harm seriously. It’s not uncommon (recent estimates are that 37 per 10,000 girls and 12 per 10,000 boys self-harm (Morgan et al, 2017) and has a link with suicidal behaviour. ‘Don’t dismiss it, it’s an indicator of distress,’ Rory says. ‘In school contexts especially, it has to be managed and not ignored.’

‘My advice is that if you are concerned somebody may be suicidal, please always ask them directly. There’s no evidence that it plants the idea in their head,’ he says. ‘We all have a role in suicide prevention.’


New strategies

In October, Theresa May appointed Jackie Doyle-Price as the UK’s first minister for suicide prevention. In the charity sector, this step has been greeted with cautious optimism. Samaritans has already been working with the minister in her previous role as parliamentary under-secretary of state and is a member of the National Suicide Prevention Strategy Advisory Group (along with Papyrus).

‘The government’s suicide prevention strategy leaves implementation to local authorities, because it’s viewed as a public health issue,’ Oliver of Samaritans says. ‘We check that local authorities have campaigns in place, but we also campaign to ensure central government is providing support to local authorities and to ensure that there’s centralised analysis and evaluation of the campaigns, so people don’t have to reinvent the wheel locally.

‘Clearly, different locations have different needs, but if a service works in one town, chances are it won’t have to be adapted too much to work in another town.’

Policy aside, it’s daily interactions that can make a difference to those at risk of suicide. Frontline community practitioners are in contact with families constantly, and while they may not be solely tasked with suicide prevention, they can definitely be part of the bigger picture. 

THE STARK FIGURES

 

 

 

 

 

 

 

*In England and Wales, a conclusion of suicide cannot be returned for children under 10
 


Resources

  • Anyone can call Samaritans on 116 123 (24 hours a day, 365 days a year, free) or email jo@samaritans.org. You don’t have to be suicidal to call.
  • Papyrus UK is a suicide prevention charity for children and young people under 35 who are experiencing thoughts of suicide; and for anyone concerned a young person could be thinking about suicide. Visit papyrus-uk.org, call 0800 068 4141, text 07786 209697 or email pat@papyrus-uk.org
  • The Men’s Health Forum has a mission to improve the health of men in England, Scotland and Wales. Visit menshealthforum.org.uk Public Health England has a suicide prevention atlas mapping local suicide data including prevention plans and depression prevalence. See bit.ly/PHE_healthier_lives

References

BBC News. (2018) Suicide triggers in men to be studied. See: bbc.co.uk/news/uk-scotland-44281525 (accessed 18 October 2018).

CALM. (2018) Suicide. See: thecalmzone.net/help/get-help/suicide (accessed 18 October 2018).

Geering C. (2018) Civil standard for suicides: R (Maughan) v HM Senior Coroner for Oxfordshire. See: 2harecourt.com/2018/08/02/civil-standard-suicides-maughan (accessed 18 October 2018).

Dandona R, Anil Kumar G, Dhaliwal RS et al. (2018) Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease study 1990-2016. Lancet Public Health 3(10): PE478-E489.  See: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30138-5/fulltext (accessed 18 October 2018).

Morgan C, Webb RT, Carr MJ, Kontopantelis E, Green J Chew-Graham CA, Kapur N, Ashcroft DM. (2017) Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care. BMJ 359: j4351. See: https://www.bmj.com/content/359/bmj.j4351 (accessed 25 October 2018).

Northern Ireland Statistics and Research Agency. (2017) Number of Deaths From Suicide registered in Northern Ireland by Sex, 1970-2016. See: nisra.gov.uk/sites/nisra.gov.uk/files/publications/Suicide_2016.xls (accessed 25 October 2018).

Office for National Statistics. (2018a) Suicides in the UK: 2017 registrations. See: ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2017registrations (accessed 18 October 2018).

Office for National Statistics. (2018b) Deaths registered in England and Wales (series DR): 2017. See: ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredinenglandandwalesseriesdr/2017#suicide-accounted-for-an-increased-proportion-of-deaths-at-ages-5-to-19-years-in-2017 (accessed 26 October 2018).

Wyllie, C., Platt, S., Brownlie, J., Chandler, A., Connolly, S., Evans, R., Kennelly, B. et al. (2012). Men, suicide and society: why disadvantaged men in mid-life die by suicide. Samaritans: Surrey.

Samaritans. (2017) Dying from inequality. See: samaritans.org/sites/default/files/kcfinder/files/Samaritans%20Dying%20from%20inequality%20report%20-%20summary.pdf (accessed 18 October 2018).

Stein C. (2018) Mind your language: how men talk about mental health. See: shop.menshealthforum.org.uk/products/mind-your-language-how-men-talk-about-mental-health?_ga=2.36360672.1795626665.1539855223-1876428190.1539855223 (accessed 18 October 2018).

WHO. (2018) World Health Statistics data visualisations dashboard. See: http://apps.who.int/gho/data/node.sdg.3-4-data?lang=en (accessed 18 October 2018).

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