World Suicide Prevention Day 2021: complex times require clear thinking, not ideology

Sep 9

We live in times where paradox and confusion are often the norm. One example of this is that although mental illness has increased since covid-related restrictions began, the suicide rate has reduced. This is welcome news, but why has it happened? And what can we learn from this phenomenon that can help us to improve suicide prevention?

“Working from home is a godsend for someone who hates the place they work in... But for someone who lives alone and gets a lot of enjoyment from interacting with their colleagues in the workplace, working from home can be depressing”.

What has caused the recent reduction in suicide?

The reasons for this are difficult to identify with certainty. However it is possible this apparent paradox has occurred because changes in recent times – mainly related to covid restrictions such as lockdowns – have impacted different people in different ways. For example, working from home is a godsend for someone who hates the place they work in and hates their daily commute to work, so it stands to reason that their mental health might benefit due to being able to avoid the workplace. But for someone who lives alone and gets a lot of enjoyment from interacting with their colleagues in the workplace, working from home can be depressing and even lead to thoughts of suicide.

It is also possible that the impact of covid restrictions on work and home life might have special relevance for male suicides, which make up around 75% of suicides in the UK and other Western countries.

The gender paradox of suicide

In Western countries, a phenomenon exists where women on average attempt suicide and have more suicidal thoughts than men do, but die by suicide less than men do. This is sometimes referred to as the gender paradox of suicide. Suicide is complex and tends to have multiple causes, but one US study found the four main issues implicated in suicide are relationship discord or family discord (22% of suicides), relationship breakdown (18%), financial crisis (11%), and work issues (11%).

The demographic most at risk of suicide is middle aged men (around 47 years old). A UK study found that 45% of middle aged men who died by suicide lived alone, and it is relevant that relationship breakdown leads to social isolation for men more than women. 57% of the same UK sample were experiencing problems such as unemployment, financial issues or accommodation problems at the time of their suicide.

It just so happens that the key issues associated with suicide - relationships and finances - are also key areas impacted by the covid pandemic restrictions. These two issues have special relevance for men because of the importance to men of relationship stability and job satisfaction to mental wellbeing, possibly due to the relevance of these areas of life to masculinity. However the impact of covid-related restrictions on these two key areas are not straightforward, and to say they are a double edged sword is a simplification of a complex relationship.

Apart from any health impact of covid-19 (and poor health can also be associated with suicide, though is not generally thought to be causal) and the falloff in usual healthcare provision, the main impact of covid has been on people’s work life and living conditions. Changes in lifestyle such as working from home can be good for the mental health of some people but bad for the mental health of others. Examples of this were given at the start of this article, but there are a myriad of ways in which people might be impacted. For example, working from home might be painful for those who have difficult relationships with their housemates or family, but might be a blessed relief to an introverted person who lives alone. And there are those lucky people for whom spending more time with their family is an enriching experience. There are also those people who are kept in employment on furlough (i.e. paid leave), which means they potentially have a lot more leisure time without the stress of unemployment. There are lots of issues that are a relatively minor irritant under normal conditions, but under lockdown conditions can quickly become very stressful. Examples of this are arguments over sharing housework and noise from neighbours.

Some of the activities that can help people cope with stress have been restricted or banned recently e.g. travelling to see friends, going on holiday, going to the gym, or going to the pub. Other important activities and events that have been restricted are visiting elderly relatives in care homes, attending a funeral, or getting married with the usual number of friends and family present.

As can be imagined, the huge number of possible permutations of personality types, living conditions, work relationships etc mean that the impact of covid restrictions on any specific individual is a spin of the roulette wheel, leading to disaster for some, relief for others, or some combination of both for yet others.

In all sorts of ways there are unexpected outcomes that might not manifest in the short term. For example, attending a funeral can be emotionally demanding, and although being prevented from attending a funeral might prevent stress in the short-term for some people, funerals can facilitate the grieving process, and missing out on this can store up complications for the future.

“what happens when the furlough money runs out, or when the novelty of working from home begins to turn into a desperate need to be anywhere but at home?”

The complex, double-edged, nature of these various changes could be what accounts for the reduced suicide rate: despite some people becoming more stressed, others have become less stressed, and the overall stress burden is put off until another day. On the other hand, we have to wonder how long the wellbeing benefits related to covid restrictions can be sustained. For example, what happens when the furlough money runs out, or when the happy novelty of working from home begins to turn into a desperate need to be anywhere but at home for some, or an increasing reluctance to leave the house for others.

A paradox in suicide prevention research
Preventing suicide is an important goal, but there are obstacles to research in this field achieving its full potential. One obstacle is a paradox in suicide research that generally goes unnoticed: although most suicides are by middle-aged men, most suicide research focuses on young adults and teenagers, the results of which might not be relevant to the experiences of older men. This over-reliance on data from young men rather than older men is also seen in research linking masculinity to poor help-seeking and mental health problems.

The other obstacle is that a lot of research focused on mental health in men draws on the ‘deficit model’ of masculinity, despite that fact that this model, which sees ‘traditional masculinity’ as a problem, has been the focus of widespread criticism. A recent Australian programme assessed the impact on 594 schoolboys aged 16 to 18 years old of attending a one-hour presentation called Silence is Deadly, delivered by a masculine man (e.g. military or sports person), with handouts and a website. Despite feedback from the schoolboys that they enjoyed the presentation, the presentation didn’t increase their help-seeking attitudes or behaviours, or reduce any stigma they had about help-seeking. When their views were measured again one year later there was a small but statistically significant increase (from a mean of 4.28 to 4.79; p<.015) in the schoolboys’ confidence to help a friend to seek help, although it is not known how much this change in confidence reflected their actual behaviour in this regard.

Why did this programme, which had an impressive sample size and was credible in other ways, show only limited success? One possibility is that the presentation’s emphasis on “the explicit ways in which masculine norms can hinder early and effective help-seeking”, is a message that the schoolboys simply didn’t buy into. This message - based on the APA guidelines for working with men and boys – might be unappealing for various reasons, but if in the end it doesn’t achieve the desired outcome, then alternatives should be considered.

Conclusion
These are complex times, and there is no sign of things becoming simpler any time soon. If we are to improve suicide prevention, it makes sense to think clearly about realistic strategies which reflect what we know about the circumstances that contribute to suicide. In other words it makes sense to focus on family support, relationship counselling, career advice, housing support etc and develop these strategies into safe and effective interventions. Of course this approach requires adaptations in a range of services, which is a lot more challenging than adopting the reductionist approach of basing interventions on the idea that masculinity is flawed. If it is necessary to bring masculinity into suicide reduction strategies, it makes sense to utilise approaches that understand how aspects of masculinity can help mental health and help-seeking.

Although the suicide rate has dropped, we can’t be sure how long this welcome situation will last. We should waste no time in improving research to identify effective programmes that will not let down suicide victims and their families.

If you are feeling suicidal, there are people who can offer advice and support. CALM offer advice on issues in general, and can be contacted here. For problems with domestic violence, contact the ManKind Initiative. For problems with family breakdown issues, contact Families Need Fathers.

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