title: Towards an enhanced understanding of suicide risk in men
Creators: name: Richardson, Cara
Publisher: name: University of Glasgow
Year: 2021

description: Background: Suicide is a major public health concern and continues to be a significant risk for men. It is estimated that 703,000 people die each year by suicide and in 2018 men accounted for over two-thirds of suicide deaths in the UK. Also, suicides in men outnumber women in all countries and in all age groups studied by the Global Burden of Disease Survey (except the 15-19 year group). In Scotland, the highest rates of suicide were among men aged 45-54 in 2020. Recent reviews have highlighted advances in our understanding of risk factors for suicide, however, despite more than fifty years of suicide research, our ability to predict suicide is no better than chance. That is not to say that progress has not been made because it has. For example, there have been several theories of suicide proposed over the past one hundred years, from sociological, biological, and psychological. In a recent review paper, the complexity of suicidal behaviours and the development of suicide risk was outlined, which can be influenced by biology, psychological factors, clinical factors as well as social and environmental factors. Therefore, the overarching aims of this thesis are to investigate: 1) What demographic, clinical and psychosocial factors confer vulnerability for suicidal behaviour in men? 2) What factors differ between men and women regarding suicide risk? 3) Which factors are associated with suicidal thoughts versus suicide attempts in men and women? Method: This PhD thesis is comprised of 4 empirical chapters. It begins with a systematic review of the literature, conducted to investigate risk factors for suicidal behaviour in men (N = 105 studies). Then secondary data analysis of two large nationally representative datasets was undertaken, to examine sex differences in factors which associated with suicide attempts vs suicidal thoughts and factors associated with method choice. Chapter 3 analysed the Adult Psychiatric Morbidity Survey (APMS) and Chapter 6 analysed the Scottish Suicide Information Database (ScotSID). Then two qualitative studies were undertaken, following the principles of Interpretative Phenomenological Analysis, to enhance understanding of personal, social, and cultural factors in men who have attempted suicide and the male experience of suicide attempts and recovery. Results: In the systematic review (Chapter 2), the risk factors with the strongest evidence predicting suicidal behaviour in men were alcohol and/or drug use/dependence; being unmarried, single, divorced, or widowed; and having a diagnosis of depression. In the prospective studies, the most consistent evidence was for sociodemographic factors (19 risk factors), mental health/psychiatric illness (16 risk factors), physical health/illness (13 risk factors), and negative life events/trauma (11 risk factors). There were a small number of psychological factors (6 factors) and characteristics of suicidal behaviour (3 factors) identified. In chapter 3, men were less likely to report suicidal thoughts and attempts, compared to women. More factors differentiated between suicidal thoughts and attempts in women compared to in men; these included hospital admission for mental illness, below degree level qualifications, being single and childhood adversity. In men, factors which significantly differentiated between suicidal thoughts and attempts included self-report of professional diagnosis of mental illness and childhood adversity. Higher levels of social support were associated with being in the suicidal thoughts group versus in the attempts group in men. Chapter 4 revealed the pressure many of the men felt to attain the status of being a “successful man” and failing to do so affected their self-confidence and selfesteem. The prevailing impact of past experiences was also relevant. The buildup to the attempt differed among the participants although several had experienced poor mental health for a prolonged period. Also, various motivational factors emerged such as entrapment, hopelessness or perceived burdensomeness. Chapter 5 explored the suicidal process in men, from suicide attempt to recovery. The findings provide insights into how men cope with suicidal thoughts or negative emotions, often avoiding seeking help and suppressing their emotions. The men’s lives were significantly affected by the attempt, with some stating that they had changed as a person. Importantly, the findings indicate that men do recognise that they need help and can be receptive to help but can feel they need to be approached in the first instance. Finally, chapter 6 demonstrated that men who died by suicide were more likely to use violent methods compared to women. Also, the influence of other factors such as marital status, employment status, deprivation, place of occurrence at home and suicidal intent provides a more detailed account of the situation individuals were in at the time of the attempt. Conclusions: This thesis includes one of the first literature reviews of its kind, a systematic review of risk factors for suicidal behaviour in men as well as two qualitative studies and two secondary data analyses. Spanning predisposing factors, such as early life experiences and childhood education, to mental illness and health, the path towards suicide in men is multifaceted and involves a complex interplay of factors. The findings also reveal how many factors have a differential impact on males and females and future research should examine the extent to which these factors influence suicide risk over time. In addition, men’s lives can be significantly affected by a suicide attempt, demonstrating the need for support during this vulnerable period. The evidence presented in this research also has important implications for policy and clinical practice.