Five years ago, Josh was standing on a bridge, texting his brother a good-bye message. He had been severely depressed for months, and the counselling that he was receiving and medication he was on wasn’t helping much. “I had lost all sight of ever getting better, and of anything enjoyable I’d ever done,” he says.
But he didn’t die.
Despite breaking six ribs and puncturing a lung, he woke up in the water. Adrenaline and instinct led him to swim to a nearby platform, where he was soon picked up by emergency services – his brother had received his text and called 911.
Today, Josh is doing much better. But he wonders what would have happened if he’d reached out for help earlier, before his depression worsened. “I basically never talked about my emotions with anybody; I felt like I wanted to figure things out on my own,” he says. “It was only when I was obviously really sick and ill that I reached out, because I couldn’t pretend anymore.”
He now works for HeadsUpGuys, a website based out of the University of British Columbia that focuses on men and mental illness. The experience has changed his perspective on why he didn’t feel comfortable asking for professional help earlier.
“Before, I never even thought of mental health in terms of what it means to be a man. [Through my work I realized] that I probably never asked for help because of those male stereotypes,” he says. “We have 11 story videos and a whole bunch of blogs on the site, and basically every time it’s they didn’t talk about their emotions with anybody, they wanted to figure it out on their own. You hear the same story [over and over again], and it’s my story too.”
Suicide is often thought of as a gender-neutral issue, but in reality, it’s a problem that affects men far more than women. Three times as many Canadian men kill themselves every year than women do – in Ontario, that means more men are dying from suicide than from car accidents.
That’s why many argue that suicide prevention programs should recognize that men are a high risk group and tailor messaging and programming to them. That’s starting to happen, with websites like HeadsUpMen and groups like Men’s Sheds, which offer a space and tools where men can gather to work on projects and make connections. Many of these are partially funded by the Movember Foundation, a men’s health organization, which has highlighted male suicide as one of its key areas of investment.
Women are actually more likely to try to kill themselves – three to four times more likely. But men are more likely to die from it. That’s a pattern that holds true across Canada, and in most of the rest of the world as well.
That’s mainly due to two things: “One is that men use more lethal means [to attempt suicide], and the second is that they don’t seek care as much,” says Simon Hatcher, vice-chair of research for the Department of Psychiatry at the University of Ottawa.
Men are more likely to use firearms and other deadly methods, while women are more likely to use pills. These differences might be because men are more comfortable with guns. Or it might be that, as some researchers have suggested, they’re choosing more extreme methods because they’re more suicidal in the first place.
Is masculinity getting in the way of getting help?
Having mental health issues is a major predictor for suicide – almost everyone who dies from suicide has an underlying mental health problem. “Ninety percent of people who die by suicide are experiencing some sort of mental illness or addiction, most often depression,” says Ed Mantler, vice president of programs and priorities at the Mental Health Commission of Canada. But not everyone with mental illness kills themselves. So what distinguishes those who do from those who don’t?
One thing is a strong support system. There’s evidence that men who adhere more strongly to masculine ideals see getting psychological help more negatively. That can result in their feelings building up without an escape valve – either a personal one, through talking with friends and family, or a professional one, through therapy or other mental health services – and can escalate to a crisis point. Studies show that in the year before they killed themselves, only 35 percent of men saw a mental-health practitioner, while 58 percent of women did.
“If a guy says, well my sense of being a man means that I can’t disclose any vulnerabilities, because that will make me look weak, if something [like depression] does come up, what do I do with that? I have to keep it to myself,” says John Oliffe, founder and lead investigator of the Men’s Health Research program at UBC.
He also questions the commonly held belief that women are more likely to suffer from mental illness than men are. “Historically these numbers have been bandied about – that women have twice the rate of depression, but men have higher rates of suicide,” he says. “But when you look more into contemporary epidemiological research, the numbers start to look a little different.”
That’s especially true when you consider that men’s symptoms of depression may be different than women’s. Instead of crying more, for example, Oliffe’s research has shown that increased anger, risk taking, irritability and substance abuse might be more common signs of depression in men. “Men will talk about not being able to sleep, about back pain, but they won’t say they’re feeling sad and incompetent,” says Julie Campbell, executive director of the Canadian Association for Suicide Prevention.
They do, however, interact with their primary care providers: Most men who kill themselves have seen their family doctor within the month. A new online course, certified by the College of Family Physicians of Canada, hopes to better educate family physicians about signs of suicide and depression in both men and women.
“Quite often we hear from family physicians that they’re reluctant to even ask questions [about mental health]. If your doctor doesn’t ask the question, it’s unlikely that most of us would volunteer that information,” says Mantler. “So providing physicians with the knowledge to have that conversation is important.”
Some sub-groups of men are also more vulnerable to suicide: gay and transgender men, Indigenous men and those vulnerable to Post-Traumatic Stress Disorder, such as first responders and soldiers. Men who are in a lower socioeconomic class are also more likely to try to kill themselves.
Early life experiences also play a role: Having parents who separated early in their lives and a family history of suicide are much more predictive of men dying from suicide than they are for women.
And age is a factor. While suicide is often thought of as a young person’s problem, across Canada, Britain and the U.S., the group most likely to kill themselves are actually middle aged men. Nine of every 100,000 men 15 to 19 died of suicide, while 28 of every 100,000 who are 45 to 54 did. (The rate for women 45 to 54 is only 8.5 of 100,000.)
“It’s a bit of a myth that the most prevalent group is young people,” says Robert Whitley, Principal Investigator of the Social Psychiatry Research and Interest Group at McGill’s Douglas Hospital Research Center. “If you zero in on why it’s so high in the 40 to 60 age group, one of the key theories is that that’s an age where many men become unemployed or divorced.”
Job losses increase the risk of suicide two- or three-fold, and men who are single, widowed or divorced are more likely to kill themselves. Relationship breakdowns like divorce are more likely to lead men to suicide than women, possibly because women tend to have close same-sex friendships throughout their lives, while men’s same-sex friendships fade after 30.
“What’s common is that many people felt they had a sense of predictability, meaning and purpose [in their jobs, marriages or role as a father.] There’s a sense that the carpet is being pulled out from under their feet, and a sense of alienation. Suddenly they feel completely rejected and misunderstood,” says Whitley
Solutions to prevent suicides
The big picture answer to this problem, says Oliffe, is addressing the issue of masculinity in our culture. “I really do think our society and culture needs to take collective responsibility in redefining what it means to be a man,” he says. He’s hopeful that the image of men needing to be “the sturdy oak” is diminishing in younger generations.
Campbell agrees – and says those shifts need to be embraced by women, too. “Men need to learn to do things differently, but women are not that comfortable with these changes. We always say that men should be able to cry more, but it’s any man but our man. We’re still a bit stuck in those roles, and we need to work on each side.”
Simply being aware of gender in our research and our approaches is another key step. “To ask, are there times where we need to have different approaches in men and women? Even that is very powerful,” says Joy Johnson, vice-president of research at Simon Fraser and formerly the Scientific Director for the Institute of Gender and Health at the Canadian Institutes of Health Research. “We need to start to systematically think about an approach that could reach out to men and boys.”
Some examples exist from around the world: The U.S. Air Force successfully dropped suicide levels beginning in the 1990s by setting up 11 initiatives which normalize distress, encourage seeking help and educate leadership about warning signs of suicidality. After the program started, the mean suicide rate dropped from 3 per 100,000 to 2.4 per 100,000.
When Ireland had a spike in men’s suicides, they adopted Australian’s Men’s Sheds initiative, where men gather to complete projects and chat, reducing isolation in older and unemployed men in particular. Canada has also recently started embracing men’s sheds. (There is evidence that the sheds reduce isolation, though their direct effect on mental health is still unproven.)
Offering more mental health resources online and through apps might be one way to make those services more attractive to men. “Online approaches for most men work much better. We need to give them a mechanism to find out answers on their own before they’re ready to seek help,” says Johnson. “And there is a real bias towards cognitive behavioural therapy, because it’s action oriented – you create plans, you do things. The nice thing about that is it can be offered online, too.”
The number of websites tailored to men’s mental health is growing. #SickNotWeak, which was created by sports journalist Michael Landsberg, encourages users to talk about mental illness. Kids Help Phone started a “BroTalk” portal in 2015, that’s tailored to teenage men. And Head’s Up Guys, which is based out of UBC and which Oliffe consulted on, has seen 350,000 visitors since it launched in 2015. He hopes its simple design and action-oriented terms – like “act early and decisively” or “get the upper hand on depression early” – will help men feel more comfortable.
“We have very purposeful language,” says Oliffe. “We speak to guys directly, and use language that doesn’t complicate their health and (doesn’t) complicate what depression is.” Some 40,000 visitors to the site have used its self-check section, which asks about symptoms of depression. Exact numbers aren’t available yet, but many of the site’s users reported feeling suicidal every day.
A similar site in the U.S., called Man Therapy, uses humour to make men more comfortable with talking. It highlights messages like “a moustache is no place to hide your emotions” and “sometimes a man just needs a pork shoulder to cry on,” and features informative videos from “Dr. Rich Mahogany.” The site includes personal stories from men who have overcome mental illness and a self-assessment tool for depression and anxiety – what it calls a “head inspection” – and directs people to self-help resources, crisis hotlines, and local therapists.
Within 18 months after launch, the site had had more than 350,000 visitors, nearly 60,000 of whom completed the “head inspection.” Some 17 percent said the thing they liked most about the site was that it was manly. Fifty one percent of people who answered a pop-up survey on the site said they were more likely to seek help after visiting it. It was co-created by the Colorado Department of Public Health and Environment and a marketing company, and versions have since spread to other parts of the U.S. and to Australia. It has also been customized for first responders.
And of course, the last part of this is making sure that mental health resources are there for the men and women who do reach out by investing more in mental health, especially psychotherapy.
“People are always contacting me, like ‘I need some help, but I can’t pay,’ and I’m handcuffed, there’s no one to send them to,” says Oliffe. “But the main problem is that men aren’t coming through the door in the first place.”