The death of Robin Williams highlighted the role depression, anxiety and severe illnesses (such as Parkinson’s in his case) can play in the act of suicide, while the launch of the World Health Organisation’s first ever World Suicide Report showed that men are almost twice as likely to commit suicide than women.
There are differences related to cultures and countries, but men are more likely to complete the act of suicide whereas women are more likely to attempt suicide. As a result of the British legacy in many countries in the Commonwealth, the act of suicide remains illegal, so if your gun does not get you, the legal system will. More than 40 years ago, looking at low rates of suicide in black men in New York, it was observed that the rates of suicide were indeed low but those of homicide in this group were high, indicating that men swaggered their way out by arguing, ‘I will kill or get killed.’ Men tend to use more violent methods in completing suicide, and they tend to deal with their depression by drinking or through aggression or acts of violence.
What stops men from seeking help early?
Social expectations about masculinity, particularly the view that men will be able to cope as they are perceived to be stronger, may contribute to a perception that it is unmanly to seek help. The way boys are brought up not to cry means that men may find it extremely difficult to express their feelings to anyone, including their male friends. Such a phenomenon is even more common in certain cultures. Geert Hofstede, a Dutch sociologist, posited that cultures have five dimensions, one of which is related to masculinity/femininity. These attributes are related to learned styles of inter-personal interactions. Masculine cultures suggest that boys don’t cry and should fight back and prevail in performance games. Competitive sports are part of the school curriculum and macho behaviour in the workplace is expected. In cultures with a high masculinity index, the engine power of their cars is important to men and they live in order to work. In such highly masculine societies the fate of the poor is seen as the poor’s problem, thus any failure to achieve is personal rather than systemic. Men become more attractive to women by their achievement and status. Among the masculine cultures are Japan, German-speaking countries, Latin American countries and English-speaking countries such as the US, UK, Australia, New Zealand and Ireland. These cultures encourage men to be macho and in control of everything including their emotions. They may therefore find it difficult to express some emotions in particular those of sadness, tearfulness and depression as ‘men don’t cry’. This means that a lot of these feelings get internalised, making it difficult to seek help.
Men also tend to use more macho and violent methods of suicide such as hanging, guns or jumping from heights. Often feeling low is accompanied by tiredness and variations in mood as the day progresses, sadness, tearfulness, sleep disturbances and altered sleep patterns, low libido, poor appetite and loss of weight. Depression in men can often present with irritability, outbursts of sudden anger, increased loss of control, risk-taking, aggression and increased alcohol intake to mask feelings of depression and irritability. Men may also use drugs more often to self-medicate and hide feelings of depression, as the general stereotype is that men do not get depressed and if they do, it is ‘moral weakness’.
Therefore men tend to cope with and manage underlying depression in different ways. Often men are competitive and depression is interpreted as a sign of failure and therefore they may find it difficult to share these feelings with anyone. They may feel isolated but may not acknowledge that. In addition, their internal world would emphasise their feeling a failure and bleak views of the world and their future. Studies have shown that between 60 and 90 per cent of those who commit suicide have mental disorders. Thus early diagnosis and management is critical.
What causes Depression?
In addition to the usual causes of job loss, failed relationships or the death of loved ones, depression runs in families. Relationship difficulties, separation and divorce, stressful jobs and lack of support at work, not being promoted or being promoted above one’s capabilities can all cause stress, which will contribute to depression. New fathers are also prone to develop depression seeing difficulties in bringing up babies. The loss of a job or lack of promotion may be seen as emasculating, leading to feelings of depression compounded by feelings of rejection and low self-esteem.
What to do?
A thorough and proper assessment is needed to ensure that there are no underlying physical causes. General practitioners are well placed to do this in the first instance so that a suitable referral to specialists can be made. This will include thorough mental-state assessment as well as physical assessment. Many physical illnesses including arthritis, diabetes, hypertension and an underactive thyroid can all cause depression.
Staying and keeping active, especially taking physical exercise, can help in some cases. It is important that partners and wives are involved in engagement of the patient. Spending time with families and friends, especially if one can share one’s feelings, may help. A balanced diet and avoiding alcohol and self-medication will also help. In mild to moderate depression, cognitive behaviour therapy has been shown to be effective. Other talking therapies may help too. However, in severe depression antidepressants may be needed. These drugs have been proven to be effective and are not addictive. The right types of medication such as a more sedating drug when the individuals are agitated and more stimulating medication when they are tired and drawn may help.
Families should remain watchful in both identifying the symptoms and signs of suicidal ideas. Supporting and encouraging their loved ones to seek help sooner and also keep a careful eye on warning of the possibility of suicide will help. Various organisations such as the Samaritans, the Mental Health Foundation and the Royal College of Psychiatrists have information leaflets in various languages and can be downloaded easily from their respective websites. Talking about feelings is not an unmanly thing but will open up various avenues so that no one has to suffer in silence.
Professor Dinesh Bhugra is President of the World Psychiatric Association and a former president of the Royal College of Psychiatrists.