As a middle-aged male, who has for many years traversed my own unique path with occasional mental health struggles, mostly brought on simply by life and its inevitable challenges, the topic of men and suicide is one that is very near to my heart. I count myself as one of the lucky ones, having managed to always overcome my hurdles and not succumb to the dark urges that haunt you during the absolute worst of times. But for many men, this is not the case, and their tales end in tragedy. Tragedy that is often preventable. I therefore felt compelled to write this piece for Men’s Health Month as I reflect on my own experiences, the importance of breaking the silence around men and mental health, and mourn the countless lives that have so sadly been lost to suicide”. – Leon de Beer, Deputy Director of SA Federation for Mental Health
NOTE: this piece deals with potentially-triggering subject matter, so please approach with caution.
BOYS WILL [OR SHOULD?] BE BOYS…
Societies tend to expect a lot from its men. They need to be in control, display confidence, be decision-makers, and provide a decisive voice of rationale and reason. Men are often portrayed as “the rock with a steady hand and mind in times of trouble and uncertainty”, stereotyped as protectors, providers, confident, fearless and dependable. Ironically though, the very traits that societies label men with can lead to them feeling emasculated and inadequate. It is not realistic to expect that men should be the ‘stronger’ sex who always abide by societies’ mottos of “what makes a man”, and that they should always simply find ways to “pull themselves together”.
Men are also less likely to seek help due to macho male stereotypes, which expect men to adopt a “boys don’t cry” and “man up” state of mind. These attitudes, which portray men to be fearless and brave, lead to men seeing themselves in a negative light if they struggle with a mental health condition. And because of this, men see that seeking help places them in a vulnerable position.
I can really relate to this. Having grown up in the conservative Afrikaans culture, there was never any real room for expressing ‘unmanly’ emotions, lest you were content with being called a ‘sissy’ or ‘softy’ by your friends, teachers or family members. Also, as I grew up and the pressures of adulthood mounted alongside the widely pervasive societal stereotype of “real men don’t cry”, things like employment pressures, financial responsibilities, being a husband and a father left little space for being ‘comfortably vulnerable’, often leaving me feeling overwhelmed and isolated, with little options available for support”.
SUICIDE AT A GLANCE…
Suicide is one the leading causes of death around the world, and the rates among men are considerably higher than among women in almost all countries, despite the fact that research has shown that, while women think more about suicide, men are far more likely to die by suicide. This higher suicide rate among men is a consistent trend, with men accounting for roughly 75% of the one million annual suicide-related deaths globally.
South Africa is ranked 10th on the list of countries with the most suicides, with 23.5 per 100 000 people, with a rate of up to 37.6 per 100 000 for men, and only 9.8 per 100 000 for women. However, South Africa is not unique when it comes to these types of statistics.
Suicide in men has been described as a “silent epidemic”. Silent because of a lack of public awareness on the topic, a lack of explanatory research, and men’s reluctance to seek help regarding suicide-related problems. Epidemic because of its high incidence rates and substantial contribution towards mortality rates in men.
The World Health Organisation views suicide as a global health problem, which is affecting men disproportionally, with various psychosocial and neurobiological factors being identified as playing a role. These include:
- A lack of gender-sensitive mental health services.
- Men being unwilling to engage in help-seeking behaviour with regards to mental health services.
- Impulsivity.
- Drug and alcohol use.
- Access to and use of lethal means.
My first encounter with suicide was when an old school friend of mine took his own life some years after we had left school. I remember hearing the news and being utterly devastated, but also feeling very surprised. At school, he had been a warm, friendly guy, always smiling, cracking jokes; a real jovial chap that everyone wanted to be friends with. When he passed away, a big part of the shock for me came from thinking “I would have never expected it from him of all people”. I remember sitting for days and wondering what had happened to him… I wondered whether the feelings that eventually dragged him under had already been present when we were in school and whether he had masked it behind an ever-smiling façade. Or whether things had happened after school that had pushed him towards the decision to take his own life. The experience haunted me for years afterwards, and made me realise just how little we sometimes know about what truly lies behind people’s eyes, and about the hurt and darkness that people carry, which sometimes becomes so severe that it leads to even the most happy-looking people losing their lives to suicide. The experience taught me that suicide can happen anywhere, at any time, to anyone. It terrified me, but it also educated me”.
SILENCE IS [NOT ALWAYS] GOLDEN…
The effects of men not wanting to speak out can worsen mental health conditions as men may seek out harmful coping strategies that might help dull the symptoms temporarily, but that could lead to the development of dependencies, which eventually spin out of control. Such coping mechanisms could include:
- Gambling.
- Alcohol and drugs.
- Reckless behaviour.
- Abuse.
If left untreated, depression and anxiety can trigger anger in men, leading to:
- Violence.
- Abusiveness.
- Bullying.
- Irritability.
- Explosive, quick temper outbursts.
- Feeling edgy, touchy, cranky and impatient.
- Feeling hopeless and helpless.
One of the main problems pertaining to men and suicide is the fact that surveys used for depression and for diagnosing depression have not been designed to detect depression in men, as men are more likely to present with symptoms such as:
- Risk-taking behaviour.
- Substance abuse.
- Poor impulse control.
- Irritability.
- Anger.
Therefore, because depression is not reported in surveys, many men lose their lives because of suicide due to undetected depression.
Symptoms of depression may include:
- Restlessness
- Hostility or irritability.
- Feeling pessimistic or hopeless.
- Thoughts of death, suicide or attempting suicide.
- Loss of energy, feeling run down and fatigued.
- Having a persistent empty or sad mood.
- Changes in appetite, for example losing weight due to not eating enough or gaining weight because of eating too much.
- Experiencing persistent physical symptoms that do not respond to treatment, for example digestive problems, headaches or chronic pain.
- Deteriorations in social relationships.
- Increased use of drugs and alcohol.
- Sleeping to little or too much, early morning awakening or oversleeping.
- Feeling worthless, helpless, guilty and experiencing self-reproach.
- Struggling to concentrate, making decisions and remembering things.
- Loss of interest of finding pleasure in activities and hobbies that were previously enjoyed.
Before I learned that depression in men could look like the polar opposite of what we traditionally think of as ‘depression symptoms’, I lived with many of the above… I was constantly irritable for no discernible reason, experienced ongoing problems with sleeping, I felt restless and unhappy about my place in life, I was cynical and pessimistic about everything, while constantly experiencing random physical symptoms such as extreme fatigue, headaches, back pains and stomach problems that I couldn’t explain. It was only when I reached out and started getting professional help that all the pieces fell into place and that I realised that I had been embroiled in a battle with a degree of depression, which was a real eye-opening experience for me. But once I knew what I was facing, I felt empowered and strong enough to take it on head first, and with the right combination of medication, therapy and lifestyle changes, I was able to overcome the worst of it and carry on with my life in a productive and happy way”.
Symptoms of anxiety may include physical symptoms:
- Excessive sweating.
- Muscle aches and tension.
- Racing or pounding heart.
- Shortness of breath or choking sensations.
- Agitation and restlessness.
- Insomnia.
- Fatigue.
- Diarrhoea, irritable bowel syndrome and nausea.
- Vertigo and dizziness.
- Panic attacks.
Anxiety can also have emotional symptoms:
- Problems with concentration.
- Feelings of dread.
- Avoidance.
- Persistent worry about things that could go wrong.
- Absentmindedness.
- Having nightmares and intrusive thoughts in which traumatic scenes are replayed in the person’s mind.
- Regarding events and situations as threatening when they aren’t.
- Fear of losing control.
- Being overly vigilant towards danger.
- Mood swings.
- Fear of making the wrong decisions and indecisiveness.
- Feeling edgy and irritable.
- Catastrophic thinking.
RISKY BUSINESS…
Risk factors for suicide include:
- Having a history of sexual or physical abuse.
- Mental health conditions, especially where it is linked to depression and debilitating or painful conditions or illnesses.
- Losing a loved one through disease or trauma.
- Social isolation or living on your own.
- Being unable to form or sustain meaningful relationships.
- Being bullied within the work or educational environment.
- Relationship breakdowns or divorce.
- Unemployment.
- Imprisonment.
- Using alcohol or drugs to help you cope with relationships, emotions, work pressures or other problems.
Any significant change in mood or behaviour can be a warning sign that someone may be thinking about suicide. This includes:
- Heightened levels of anger or irritability.
- Increased use drugs and/or alcohol.
- Disconnecting from family and friends, for example not calling as much as always, not going out etc.
- Making uncharacteristic or offhand comments about hopelessness or expressing feelings such as being a burden to other people.
- A loss of interest in activities or hobbies that were previously enjoyed.
- People seeking out ways in which to take their lives, or already having a plan to do so.
- People talking about wanting to die or take their own life.
- Denying or not experiencing emotions and feelings.
- Increased risk-taking with ambivalence about the potential consequences.
When looking at mental health conditions and suicide in men, the following groups may be more at risk than others:
- Men who have experienced trauma – traumatic events, such as being the victim of an assault or having experienced military combat, can increase the risk of men developing post-traumatic stress disorder.
- Men who are experiencing problems with employment – having a high workload or working in poor conditions can increase the risk of mental health problems. Retirement and unemployment can also increase the risk of depression and suicide in men.
- Older, white men – white men aged 85 and older are most at risk of suicide. More men in this age group lose their lives by suicide every year than men in any other group by gender, race or age.
- Men with financial or legal problems – experiencing financial or legal problems may trigger the development of mental health problems and also increase the risk of suicide.
- Men with a family history of mental health problems – many mental health conditions, for example depression, bipolar and schizophrenia, can run in families, which suggests a genetic component.
- Men who misuse drugs or alcohol – men are more likely to engage in the illicit use of alcohol and drugs, which may worsen or trigger mental health conditions.
- Men who are experiencing marital breakdown – depression is more severe and common among men who are divorced. Some research has suggested that being single is a significant trigger for suicide in men.
- Men dealing with other life challenges – other risk factors for mental health conditions and suicide in men include conflict with friends or family, physical discomfort or illness, or illness or death of a relative.
NO RHYME NOR REASON…
While the reasons for suicide in men are not always known when compared to other genders, factors like ethnicity, age, occupation and the stigma attached to male mental health are some contributing factors.
In older men, suicide is very strongly associated with physical pain and illness, depression, feelings of guilt and hopelessness, and living alone.
In addition to the aforementioned risk factors, there are a few other theories about why men are at a higher risk of dying by suicide:
- Depression may be under-diagnosed in men – men often do not disclose their feelings of depression to, for example, their doctors. When they do, it is often described as having problems with relationships or with work. Men also tend to describe their feelings as stress-related instead of as hopelessness or sadness.
- Men are less likely to seek help for emotional problems – research has shown that depression is diagnosed less frequently in men because of men’s tendencies to self-monitor symptoms, deny illnesses and self-treat.
- Men may be more likely to self-treat the symptoms of depression with alcohol and other substances.
- Traditional male gender roles discourage men from expressing emotions – men are taught that they need to be tough and that they should not ask for help. Such stern gender norms can make it difficult for men to reach out and ask for assistance when needed.
SO HOW DO WE HELP MEN…?
People who experience suicidal thoughts often report experiencing a type of ‘tunnel vision’; being unable to see the broader picture and thinking only in black and white. When feeling like this, the person might not be motivated to look for help, and it thus falls on other people to provide support through listening, offering encouragement, and occasionally even challenging the preconceptions that people might hold about themselves, for example their worth to society and their abilities.
I remember when I was going through the breakdown of my first marriage… I used to sit and stare aimlessly out of the window for hours, with the colour literally draining out of the world. I felt alone, numb, hopeless, lost, and the future seemed, well… There didn’t seem to be a future for me in this world. The above-mentioned ‘tunnel vision’ had set in, and all I could see was a life of despair, devoid of any direction or meaning, ahead of me. Until someone stopped one day and simply asked me: “Are you ok? You haven’t been yourself lately”. In that moment, I was immediately at a crossroads – either I said yes and continued along the steep declining road I was on, or I admitted that I was not ok, and reached out for help. Fortunately, I opted for the latter and – long story short – here I am, almost ten years later, happily married [for the 2nd time], with a firm grasp on my role as father, husband, manager, and with a rekindled passion for life, my work and making a difference to the world. All it took was one empathetic voice who cared enough to extend a helping hand, and that quite literally saved my life”.
There are strategies that societies and individuals can use to help reduce the risk of suicide in men. These include:
- Looking out for signs of depression – recognising that the symptoms of depression in men include social withdrawal, a loss of interest in pleasure, anxiety, irritability, physical pains and complaints, the misuse of alcohol and drugs, engaging in risky behaviours, and being unable to sustain normal daily tasks.
- Educating men about problem-solving and coping skills – this can help men manage their challenges with relationships, work and health issues.
- Creating opportunities to bring people together to forge social connections and find support.
- Ensuring that mental health support options are available readily.
- Restricting access to lethal methods of suicide, for example prescription medications and firearms.
- Do not ignore the signs – do not dismiss or make light of comments that might point to suicidal thoughts or behaviours. If you hear someone talking about suicide or making statements about suicide, encourage them to talk to a professional or health care provider.
- Offering support – if you see signs of depression, ask what you can do to assist and let the person know that you are there to help and listen.
This type of practical and emotional support is important for assisting people to adjust their circumstances and to restore their well-being.
At the end of the day, everyone can play a role in helping to reduce male suicide rates on both a macro and micro level:
- At a macro level, we can aim to try and lower male suicide rates by continuing to remove stigma. While progress has been made over the years, and men are becoming more comfortable to talk and express themselves, we still have much work to do.
- Increasing the amount of mental health care can further contribute towards helping to lower suicide rates in men, while also helping to improve their overall quality of life.
- Addressing issues such as homophobia and transphobia, systemic racism and social isolation among older men in our societies can all assist in lowering suicide rates.
- Offer the men in your life direct support; look out for symptoms and signs of depression, and let them know that you are there for them. Remember to always take any potential signs of suicidal ideation seriously.
- Ensure that the men in your life know where to find support, either through family and friends, a therapist, their doctor, or local organisations [for example the SADAG’s 24-hour suicide crisis line 0800 567 567].
- Remember that pursuing therapy is key to good mental health, and it is important to help normalise the idea that going for therapy is ok if you’re a male.
Further tips for reducing suicide among men include:
- On an individual basis, we can create safe spaces to express and share emotions through non-judgemental, open conversations and gentle questioning. If someone you know is showing some of the warning signs, talk to them. You can start by mentioning some of your concerns, for example “I haven’t heard from you that often recently; is everything ok?”.
- Keep conversations going by listening to what men are saying and asking questions. However, you don’t have to offer solutions. If you still feel worried about them, you can ask “Are you thinking about suicide?”. If they respond by saying yes, try not to panic. Let the person know that you are there for them and assist them to access mental health support by, for example, giving them a crisis line number [refer to SADAG number listed earlier]
- As individuals, we can express and show emotion, ask for help when needed, and let others know that it’s ok for them to do the same. We can also aim to have more meaningful conversations by, for example, asking “How are you really doing?” if we think someone is struggling.
At a community level, we can help reduce male suicide through:
- Workplaces making employee resources easily accessible, well-known and confidential.
- Healthcare providers identifying men who may be contemplating suicide by being alert to subtle cues that may indicate that they are struggling; this could include things like tone of voice or body language.
- Improve training for professionals to ensure that they are better able to detect depression in men.
But how do we reduce the risks and help build resilience in men? The following factors can help contribute towards this:
- Looking for support when it is needed – men who seek help to deal with overwhelming emotions are more likely to receive it before they consider suicide.
- Enabling supportive, positive and close relationships with friends, family and co-workers – people who are supportive can be asked for help, and they can also offer it; they are able to provide a safety net for a male when he is struggling.
- Being comfortable expressing and showing emotions – men who embrace their emotions and recognise the importance of sharing them with others are better able to cope because they are more likely to deal with them before they become overwhelming.
Helping men often just comes down to those around them not being scared to ask whether they need help, and assisting them to find appropriate forms of support. It really isn’t rocket science. It’s simply about stepping beyond societal stereotypes and acknowledging that “big boys do in fact also cry”. It’s about being in tune with and caring for those around you and realising that nobody is superhuman or immune to mental health problems.
So my plea to all readers of this article is this… If you are worried about a man in your life, or if you suspect that they are not ok, they probably aren’t, and they need your help. So be THAT person… The one that extends the empathetic hand and that helps the person understand that it’s ok to be vulnerable, to seek and to pursue help. One small gesture at a time, we can all make sure that men get the support they need, and that fewer and fewer lives are lost to suicide”.
Written by Leon de Beer, Deputy Director of SA Federation for Mental Health
Help is available. The National Suicide Crisis Line is 0800 567 567. This number is free, operates 24/7 and offers counselling in all 11 official languages.
