Course:SOWK551/2021/Suicide and Suicide Prevention for Canadian Men: A Literature Review and Implications for Social Work Practice
Suicide and Suicide Prevention for Middle and Older Aged Canadian Men
Author: Anonymous
Date: April 8, 2023
Introduction
According to the 2022 Progress Report, The Federal Framework for Suicide Prevention (The Framework), suicide was the ninth leading cause of death in Canada in 2019, and the mortality rate was higher among males in all age groups compared to females. Bilsker and White discuss how suicide rates peak for Canadian men in their 40’s and 50’s and that this age and gender group has not been studied extensively (2011). Male suicide in Canada is an epidemic that is largely invisible. Because of the lack of awareness of this public health issue, preventative measures to specifically target men have been scarce. Research and resources have not yet been adequately allocated to appropriately address this crisis. Bilsker and White explain that men’s reluctance to seek help for suicide-related concerns and the stigma associated with mental health problems has led to discussion and recommendations about prevention, screening, treatment, and service delivery (2011). Oliffe et al. notes that one prevention strategy includes diagnosis and effective management of men’s depression (2016). While depression is a factor in male suicide, it is not the only factor. However, this literature review reveals the impact of depression and its relationship to this health issue as related to social work practice. Oliffe et al. explains that reviewing the “deeply entwined issues to better understand and address the discordant relationship between men’s low rates of formally diagnosed depression and high rates of suicide”, is intended to implement clinical services, promote mental health, and reduce male suicide (2019). For middle and older aged men, certain factors were predictors of suicide and suicidality. This includes living alone, low education, low income, living in areas with higher social and material deprivation, having depression or anxiety, and accessing mental health services the year prior to suicide according to Oliffe et al. (2021). With these social determinants of health identified, social workers in the healthcare system can address these predictors within an interdisciplinary team.
In the Provincial government’s report, A Pathway to Hope: A roadmap for making mental health and addictions care better for people in British Columbia, British Columbians are shown to have difficulty navigating between primary, community, acute, and emergency services. This is due to fragmented services causing systematic barriers which delays folks in seeking support until the care they require is costly and extensive (2019). All levels of government and health care professionals have a responsibility to prevent harm and ensure equitable access to resources. This is particularly salient for marginalized communities. Canadian middle aged and older men are not typically viewed as a vulnerable population; however, statistics demonstrate the alarming relationship between male suicide and depression. The Canadian Association of Social Workers Code of Ethics (2005) commit the profession to reduce barriers, oppose prejudice, and challenge stereotypes, which applies to this issue and population. With primary care doctors screening for depression, social workers engaging in clinical practice, and addressing stigma with mental health literacy, moving towards a national strategy of suicide prevention is possible to prevent male suicide.
Educate Primary Care Physicians in Depression Management
A strategy in suicide prevention is training primary care physicians to screen for depression. Mann et al. discusses how doctors in primary care and other nonpsychiatric care settings see 45% of future suicide decedents 30 days prior to suicide and 77% within 12 months (2021). Educating general practitioners to screen and treat depression can lower suicidal ideation and attempts. Education is key to identifying and treating this predictor of suicide. Mann et al. further explains that 90% of decedents had a current diagnosable psychiatric disorder that was untreated at the time of death. Depression was most often the undiagnosed mental illness (2021). Because men face challenges in accessing health care due to systemic barriers and reticence about discussing mental health, front line doctors must be trained to provide early intervention. The significant number of decedents attempting to seek support from nonpsychiatric healthcare professionals demonstrates a gap in the system that can be readily addressed to reduce suicide rates. In addition to educating and training for primary care physicians, screening tools to identify male depression are needed.
Bilsker and White detail how there are no specific instruments used for screening suicidality in men in primary care. Because depression is a common precursor in suicide, using a brief questionnaire is currently utilized for both men and women (2011). As previously discussed, men’s suicidality increases with certain factors like depression, living alone, and with higher social and material deprivation. With men’s reluctance to discuss emotional distress accompanied by the social stigma of mental health, “the development and validation of protocols for male-appropriate suicide assessment and intervention would greatly support health care providers in responding effectively to men’s suicide risk” (Bilsker & White, 2011, p. 533). The high rates of men’s suicide and low rates of diagnosed depression can no longer be ignored. Primary care physicians can screen men for depression and suicidality more effectively with tailored instruments. Oliffe et al. reiterates the combination of men’s reluctance and/or inability to fully engage in professional health services, along with generic depression screening tools are limitations which require gender-specific services to advance men’s help-seeking behavior (2016). Addressing barriers in health care to support men seeking mental health services can save lives that social work can support in.
Application to Practice
Psychotherapy
Using the biopsychosocial assessment, social work can incorporate cognitive behavioural therapy (CBT) to support the interdisciplinary team identify depressive symptoms and gender-specific suicidal predictors in both hospital and community settings. Utilizing this therapeutic modality “may work by improving negative problem oriented and emotion regulation […], reducing impulsiveness […], and attenuating suicidal ideation” (Mann et al., 2021, p. 617). Clinical social workers can support men identify triggers and explore coping strategies. Identifying contributing factors for suicidality is key as well as protective factors in men’s lives. This intervention supports building a therapeutic relationship and the opportunity to delve into root causes of suicidal ideation. Mann et al. explains that suicide risk can be understood within a stressdiathesis model where stress derives from both internal and external factors, and that CBT decreases suicidal risk in adults while also reducing reattempts in patients presenting to the emergency department (2021). Internal stressors are often mental illness while external stressors are life events (divorce, job loss, etc.). Oliffe et al. explain how middle-aged men who died by suicide were more socially isolated and estranged from health care professionals (2021). Using systems theory, social work can provide education about the micro and macro barriers contributing to the challenges of accessing health services which can reduce shame. Social work can also help men identify personal obstacles to their well being. Additionally, social work brings a social justice lens illuminating the socioeconomic factors that impede men from receiving care, and what can be done to overcomes these challenges. Incorporating a strength-based approach with CBT can empower men to regain control of their emotions and circumstances in a way that offers hope and support from the health care system. This assistance is strengthened with follow up in community.
Follow up/Outreach
Engaging with patients who have attempted suicide through outreach and follow up is another practice that social work can be involved in. According to Mann et al., interventions including follow up phone calls, text messages, in person contact, postcards, and psychoeducation reduces suicidal behaviour and subsequent attempts (2021). The connection and support patients need within hospital and in community must not cease once their appointment ends or are discharged. The vulnerability of reattempting suicide is the greatest one month or a year after the initial attempt (Mann et al., 2021). Social work can participate in risk assessment, safety planning, CBT, psychoeducation, and follow up. Community social workers are more flexible to engage in outreach rather than hospital social workers. The issue is connecting patients to supports they can access once they return to their daily environment. This exemplifies “gaps in continuity of care between inpatient and outpatient systems and between emergency departments and outpatient care” (Mann et al., 2021, p.619). Suicidal patients falling through the cracks reflects a systemic failure in healthcare that social work can support in filling through follow up and outreach. Another practical aspect in preventing male suicide is reducing stigma and increasing mental health literacy.
Reduce Stigma and Increase Mental Health Literacy
In A Pathway to Hope, folks living with mental illness report judgement by others as a significant barrier to recovery where stigma prevents help seeking out of fear of what others may think (2019). For men struggling with suicidality, the lack of information, misrepresentation of folks living with mental illness, and prejudicial language are multilayered barriers that hinder them from reaching out. Additionally, “men’s alignment to idealized masculinities that condone the expression of anger […], and solitary pursuits as every day manly practices is purported to mask internalizing depressive symptoms […] and suicidality” (Oliffe et al., 2019, p. 3). The normalization of social isolation and hiding depressive symptoms in the form of aggressive behaviour reduces men’s ability to seek support from a societal perspective. The act of not asking for help is considered masculine which marginalizes men in harmful ways. Normalizing help seeking behaviour for men reduces stigma shifting the narrative of what it means to be healthy and masculine.
Minimizing men’s shame in seeking help also includes improving mental health literacy. Mental health literacy is “knowledge and beliefs about mental disorders, which aid in their recognition, management, or prevention” (Oliffe et al., 2016, p. 521). Men must be able to access, interpret, and incorporate health information within a health promotion framework. Increasing men’s knowledge about depression and suicide empowers them to identify what they are experiencing and take steps to appropriately treat it. The Framework explains that high suicide literacy among the public is connected to an increase in health seeking behaviours among those who require help (2022). Raising awareness of mental health and suicide can lead to less deaths by suicide. This must be gender specific to target men in a sensitive and non-judgemental way.
Provincial and Federal Government Active in Suicide Prevention
British Columbia has laid out plans to enhance the provincial crisis line network. In A Pathway to Hope, the Provincial Health Services Authority will lead this development which will provide suicide prevention and intervention services in an efficient manner that will be streamlined and not duplicated by multiple service providers (2019). This is a priority action for the government to provide seamless and equitable access to care. Information, referrals, and emotional support will all be provided by the crisis line.
On a Federal level, The Framework explains plans to launch a nation-wide crisis line, 988 on November 30, 2023 (2022). This crisis line will be available 24/7/365 days a year in both English and French for folks in need of a mental health intervention and suicide prevention. This number will replace the current Talk Suicide Canada phone number (1-833-456-4566) to be easier to remember for those in emotional distress. The Government of Canada has invested $21 million between 2020-2025 into this new crisis line to be overseen by the Centre for Addiction and Mental Health.
With significant investments in crisis lines at both levels of government, it is worth noting that efficacy for reducing suicide rates for middle age and older Canadian men by crisis lines are absent in both government reports. Based on the literature review, men are hesitant to discuss emotional problems with primary care physicians and engage in traditional notions of masculinity regarding social isolation and anger to mask depressive symptoms hindering help seeking behaviour. Therefore, it is unlikely men will access this service because, “it is uncertain if […] crisis lines […] prevent suicide” (Linskens et al., 2022, p. 8). Creating a cohesive crisis line service across BC and Canada is valuable and necessary. However, this intervention may not reach the vulnerable group of middle aged and older men who are dying by suicide at an alarming rate in Canada.
Suicide Prevention Lacks National Strategy and Focus on Men
Contrary to the Provincial and Federal government’s stance of being proactive in suicide prevention, gaps have been acknowledged. Men are not identified as an “at risk” group nor have tailored suicide prevention efforts been made despite ongoing evidence that men die three times the rate of women in Canada (Oliffe et al., 2021). The literature review revealed that men’s rates of suicide peak in their 40’s and 50’s, and that social determinants of health including living alone, low income, and having high rates of undiagnosed depression are predictors of suicidality in men. Despite these specific factors of individuals at risk of suicide, “Canada operates without a designate suicide prevention research program focused on services for boys and men” (Oliffe et al., 2021, p. 435). The Framework was passed into legislation in 2012, and the public health issue of suicide specifically impacting Canadian men remains invisible. While the Framework (2022) has released its’ fourth progress report since being passed, it is only now that the Government of Canada states it will be going to develop a National Suicide Prevention Action plan (The Action Plan). The prolonged effort to create The Action Plan creates a gaping hole in services and resources that could be implemented to support men suffering now and who are dying preventable deaths.
Eggertson and Patrick agree that a framework is not sufficient to address suicide in Canada. They argue that a national strategy is needed to “provide clear roadmaps, with goals, timelines, resources, assigned responsibilities and a robust plan for their evaluation” (2016, p. 309). In this way, federal and provincial-territorial governments are held accountable to implement effective interventions across the country with resources and agency partnerships. The Framework falls short of this. Additionally, Eggertson and Patrick argue that suicide prevention extends beyond mental health. It involves improving and coordinating upstream factors associated with suicide including the justice, education, employment, and social welfare sectors (2016). These areas intersect with aspects of Canadian men’s lives regarding internal and external stressors. Without a national strategy and highlighting how Canadian men are disproportionately impacted by suicide, prevention efforts remain limited in scope.
Conclusion
In conclusion, Canada needs to highlight the alarming rate of Canadian men dying of suicide. It is important to note there are sub-populations among men who are also at an increased risk of suicidality. This literature review focused on middle aged and older men to capture that male identified Canadians are at an increased risk demonstrating the urgency to address that half the population is marginalized regarding suicidal predictors and dying in silence. Investing more research to understand the reasons why “will give us a stronger basis for designing programs to prevent suicide in the general male population […] with identified mental health problems” (Bilsker & White, 2011, p. 530). Addressing men’s low rates of undiagnosed depression and reluctance to help seeking behaviour is paramount. Training primary care physicians to screen and treat depression can save lives. Investing research into gender-specific screening tools can be a preventative measure implemented in the future. Social work’s role is to support male patients through CBT and exploring their triggers to suicidality in a safe and competent way. Providing education about coping strategies and institutional barriers such as toxic masculinity can provide reprieve from shame they may feel. Reducing social isolation and stigma by raising awareness about the prevalence of male suicide in our society increases mental health literacy. While the government of BC and Canada has taken admirable initiatives towards suicide prevention, it still falls short of targeting Canadian men. Advocating for a national strategy that identifies men in their 40’s and 50’s as an at-risk group can significantly reduce suicide.
References
British Columbia. (2019). A Pathway to Hope: A roadmap for making mental health and addictions care better for people in British Columbia. https://www2.gov.bc.ca/assets/gov/british-columbians-our-governments/initiatives-plans-strategies/mental-health-and-addictions-strategy/bcmentalhealthroadmap_2019web-5.pdf
Bilsker, D., & White, J. (2011). The silent epidemic of male suicide. BC Medical Journal, 529-534.
Canadian Association of Social Workers. (2023, April 7). Code of Ethics. https://www.casw-acts.ca/files/attachements/casw_code_of_ethics.pdf
Eggertson, L., & Patrick, K. (2016, September 20). Canada needs a national suicide prevention strategy. [Editorial]. Canadian Medical Association Journal. https://www.cmaj.ca/content/188/13/E309 DOI:10.1503/cmaj.160935
Government of Canada. (2022). Working Together to Prevent Suicide in Canada The Federal Framework for Suicide Prevention 2022 Progress Report. Working Together to Prevent Suicide in Canada.pdf
Linskens, E. J., Venables, N. C., Gustavson, A. M., Sayer, N. A, Murdoch, M., MacDonald, R., Ullman, K. E., McKenzie, L. G., Wilt, T. J., & Sultan, S. (2022). Population and Community Based Interventions to Prevent Suicide: A Systematic Review. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 1-11.
Mann, J. J., Michel, C. A., Auerbach, R. P. (2021). Improving Suicide Prevention Through Evidenced-Based Strategies: A Systematic Review. Am J Psychiatry, 611-624.
Oliffe, J. L., Hannan-Leith, M. N., Ogrodniczuk, J. S., Black, N., Mackenzie, C. S., Lohan, M., & Creighton, G. (2016). Men's depression and suicide literacy: a nationally representative Canadian survey. Journal of Mental Health, 520-526.
Oliffe, J. L., Kelly, M. T., Montaner, G. G., Links, P. S., Kealy, D., & Ogrodniczuk, J. S. (2021). Segmenting or Summing the Parts? A Scoping Review of Male Suicide Research in Canada. The Canadian Journal of Psychiatry, 433-556.
Oliffe, J. L., Rossnagal, E., Seidler, Z. E., Kealy, D., Ogrodniczuk, J. S., & Rice, S. M. (2019). Men's Depression and Suicide. Current Psychiatry Reports, 1-6.
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