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Depression and suicide in men
Written by Dr Ciaran Mulholland, consultant psychiatrist/senior lecturer in mental health
What is depression?
Depression is often used in everyday language to mean straightforward and understandable unhappiness. This use of the term is best avoided. Instead, the word should be reserved for those who have significant and pervasive lowering of mood leading to difficulties in leading a normal life. Such conditions can vary from a lifelong predisposition to low mood (known as dysthymia) to depressive episodes that vary in intensity from relatively mild to severe.
Depression is likely to be one of the greatest, if not the greatest, disease burdens of the 21st century. It is a very common condition that causes a great deal of suffering and a substantial number of deaths. Depression leads to disharmony at home, difficulties at work and internal distress. Unfortunately, the condition still attracts much stigma, is not always recognised and, when recognised, is not always adequately treated. Depression is more common in women than in men, though its most dramatic outcome, death by suicide, is more common in men.
How is depression diagnosed?
The diagnosis of depression is made when several core features are present:
·pervasive low mood
·loss of interest and enjoyment (anhedonia)
·reduced energy and diminished activity.
Other features can also be present, including:
·poor concentration and attention
·poor self-esteem or self-confidence
·ideas of guilt and unworthiness
·a bleak pessimistic view of the future
·thinking about, planning, or attempting suicide
·crying for no reason
·decreased interest in sex.
Depression is often more difficult to diagnose in men because they do not complain of these typical symptoms so often. They are less likely to admit to distress and if they do consult their doctor, tend to focus on physical complaints.
How common is depression?
In community surveys, 2 per cent of the population suffer from pure depression at any one time. Some have a mild form of the illness, some moderate and some severe, in roughly equal numbers. Another 8 per cent of the population suffer from a mixture of anxiety and depression at any one time. Other people do not have symptoms severe enough to qualify for a diagnosis of either anxiety or depression but have impaired working and social lives and unexplained physical symptoms.
The lifetime rate of depression is 8 per cent for men and 12 per cent for women, and these figures seem to be rising. This trend is worrying and has been much discussed. Depression is now more frequently diagnosed in younger people than it was previously. This change could well be a result of the increasing social fragmentation, including family breakdown, seen over recent decades.
How is depression treated?
Mild episodes of depression often get better without treatment or will respond to simple measures such as changes in the social environment or the family situation. Many other patients can be treated adequately by their GP. Only a minority of patients ought to be referred to specialist psychiatric services.
Patients who should be referred include those:
·who are thought to have a high risk of committing suicide
·who fail to respond to the usual treatments
·in whom the diagnosis is confusing or difficult to make.
If depression co-exists with other conditions that complicate treatment, such as a physical illness, patients should usually be referred to a specialist. Patients with a psychotic depression, who are troubled by delusions (abnormal beliefs) or hallucinations, should always be referred.
Psychotherapy and counselling
Surveys clearly show that patients prefer a psychotherapeutic approach (counselling or talking about their problems) or at least expect such an approach in combination with their medication. Evidence indicates that certain specific forms of psychotherapy are useful for patients with mild, moderate and severe depression. Their usefulness is most obvious in the milder forms and in the prevention of further episodes of depression. Men are less likely to ask for this form of treatment.
Since the late 1950s, effective medication has been available for depressive illness. In recent years, new antidepressants, with fewer side effects, have become available. These are effective for most people and relatively easy to tolerate. Whichever antidepressant is used, it is important to continue treatment for six to nine months after symptoms resolve otherwise symptoms might return quickly. Antidepressants are equally effective in men and women.
Approximately half of all patients with depression only ever have one episode. The others suffer from a recurrent form of the illness. Taking this into consideration, the doctor might think it wise to prescribe maintenance treatment, which means continuing antidepressants for a number of years to prevent further episodes.
The art of treatment is to combine social, psychological and pharmacological approaches to reduce suffering and mortality. The advent of the new antidepressants and the increasing evidence that certain forms of counselling (problem-solving and cognitive-behavioural therapies) do work means that we can be optimistic about the future for people with depression. However, depression becomes chronic in 10-20 per cent of cases.
Patients with psychotic depression are seriously ill and will almost always require hospitalisation. Antidepressant therapy alone is unlikely to be effective. The treatments of choice are either electroconvulsive therapy (a highly effective but controversial treatment that involves passing electricity through the brain under general anaesthetic) or a combination of an antidepressant with an antipsychotic medicine (a type of medication that treats delusions and hallucinations).
Suicide and men
Suicide accounts for l in 100 deaths but the majority of those are men. A worrying recent trend is the increasing rate of suicide among younger men (a trend not seen among young women). The majority of these men have not asked for help before their deaths. The suicide rate in men also increases in those aged between 65 and 75 years. In contrast, the suicide rate in women varies less with age.
The higher suicide rate among men is a worldwide phenomenon. A few exceptions to the general rule exist, for example, among elderly women in Hungary and in some Asian countries. The reasons why men are more likely to kill themselves than women are complex and ill-understood. However, several pointers help our understanding.
Risk factors for suicide
As well as being male, several other risk factors for suicide have been identified.
·Age: suicide in men peaks in the 20s and again in the 60s and 70s.
·Unemployment: the suicide rate has been shown to rise and fall with the unemployment rate in a number of countries - half of the record 33,000 people who committed suicide in Japan in 1999 were unemployed.
·Social isolation: those who kill themselves often live alone and have little contact with others; they may have been recently widowed or have never married.
·Chronic illness: any chronic illness increases the risk of suicide.
·Certain occupations: people with certain occupations are more likely to die by suicide, for example farmers (who usually work alone, may be unmarried and have access to the means of suicide, such as a shotgun or poisonous weedkiller).
Many of the above risk factors affect men more than women. It is important to remember that many people are subject to these factors, but only a tiny minority of them will end their own lives.
Other factors are also significant. The most important risk factor is the presence of a mental illness. The most important protective factor is the presence of good support from family or friends.
Research has shown that the vast majority of those who kill themselves are mentally ill at the time of their death. Two thirds are troubled by a depressive illness and 20 per cent by alcoholism.
Of people with severe depressive illnesses, 10-15 per cent will commit suicide. Paradoxically, as mentioned above, depressive illnesses are more common in women, but suicide is more common in men. Several possible explanations exist for this apparent discrepancy.
·The more severe the depression is, the more likely it is to lead to suicide. So one possibility is that more severe forms of depressive illness are equally common in men and women. In addition, once men are depressed, they are more likely to end their lives. They are also more likely to choose especially lethal methods when they attempt suicide, for example, hanging or shooting. Depressive illness among people under 25 years of age is probably much more common now than it was 50 years ago, which may account for one reason why the suicide rate is increasing in young men.
·Alcoholism leads to suicide in 10 per cent of affected people. Alcoholism is much more common in men (though it is increasing rapidly among women).
·Schizophrenia (a relatively uncommon condition affecting 1 in 100 of the population) leads to suicide in 10 per cent of affected people.
Why is the male suicide rate rising?
The reasons why the number of men taking their own lives has risen in recent years are far from clear. All of the proposed explanations share a common feature - the changing role of men in society.
·Adolescence has been prolonged, with adulthood and independence reached at a much later age than previously. Two generations ago, work began at the age of 14; one generation ago at 16 years for most; now many men only achieve financial independence in their 20s.
·Men have a more stressful time in achieving educational goals than in the past and are now less successful than women.
·Work is much less secure and periods of unemployment are the norm for many (psychologically the threat of unemployment is at least as harmful as unemployment itself).
·Alcohol use, and abuse, has increase markedly since the Second World War. Such use is often an attempt to cope with stress and to self-medicate symptoms.
·Illegal drug abuse has become much more common (a correlation between the youth suicide rate and the rate of convictions for drug offences has been demonstrated in some countries).
·Changes that are assumed to be symptoms of the 'breakdown of society' are associated with a rising suicide rate (examples include the rising divorce rate and falling church attendances).
Boys don't cry
In many societies, expressing emotions, for example sadness, fear, disappointment or regret, is seen as being less acceptable for boys than girls.
This cultural stereotype is very, very difficult to shake off, though the advent of 'new men' in the 1990s has made it more acceptable for men to open up to others.
If a man, particularly an older man, does cry openly, this is often a sign of severe depression and is taken very seriously indeed by health professionals.
Some of those who 'attempt' suicide do not actually intend to kill themselves. They mimic the act of suicide by taking an overdose or cutting themselves. They do so in an attempt to change an intolerable situation or gain attention from significant other people in their lives. This process is know as deliberate self-harm or parasuicide. Such people can get considerable relief of tension and anxiety from these acts. Deliberate self-harm is more common in women, though the proportion of men who self-harm is increasing.
Some 10-15 per cent of those who attempt suicide go on to complete suicide. In other words, 85-90 per cent do not.
How does suicide affect others?
It is not true that suicide hurts no one except the person who takes his or her life. Those who are left behind will typically go through a number of stages as they grieve - denial, anger, guilt, confusion, a protective wish to prove death was accidental, and, perhaps, depression and anxiety.
Barriers to effective treatment of depression in men
·Men are less likely to recognise that they are under stress or unhappy, let alone ill.
·Men are less likely to consult their doctor when distressed.
·If they do consult their doctor, they are more likely to complain of physical symptoms (for example, stomachache) or vague ill-health.
·Health professionals are often less likely to consider a diagnosis of mental illness in men.
·Some of the young men who kill themselves without ever seeking help seem to not have an identifiable mental illness. Rather, they are troubled by a philosophical dilemma, a dis-ease (sic) of the soul, for which suicide seems the solution.
What can society do?
Something about modern life is killing more and more young men by suicide, but at the same time is not affecting young women. We need to know more about why this is happening and if necessary society must consider changes in the way we live to reduce the toll of suicide.
·About 80 per cent of women who have committed suicide will have consulted their doctors and received treatment before their deaths.
·Only 50 per cent of men will have done so.
·For men aged less than 25 years of age, the proportion is only 20 per cent.
Education campaigns might help men, and young men in particular, to seek assistance rather than suffer in silence.
What can you do?
If you have any of the symptoms of depression outlined above, consult your doctor. If you have three or four symptoms, if you feel hopeless about the future, or if the thought of suicide has crossed your mind, you should contact your doctor urgently.
If you see the signs of depression in others, advise them to consult their doctor. If someone you know threatens suicide take the threat seriously.
Remember, depression is treatable, and suicide is avoidable.
Kelleher MJ. Suicide and the Irish. Mercier Press; Cork: 1996.
Appleby L. Cooper J. Amos T. Faragher B. Psychological autopsy study of suicides by people aged under 35.British Journal of Psychiatry. 175:168-74, 1999 Aug.