Male suicide deaths: A Review of Suicide Prevention Policy in Northern Ireland. Andrew Rawding – 1st Year Social Work

Abstract

In Northern Ireland, three times more men die by suicide than women (O’Neill & O’Connor, 2020). Latest figures reveal that in 2021 there were 237 suicide deaths, the highest number since 2015, representing an increase of 18 (8.2 per cent) from the 219 suicide deaths registered in 2020.  Of these, 176 (74.3 per cent) suicide deaths were males and 61 (25.7 per cent) were females (Northern Ireland Statistics and Research Agency (NISRA), 2022). For decades the rates of male suicide deaths in Northern Ireland have been consistently high. This social policy review will discuss suicide prevention strategies in relation to male suicide deaths in Northern Ireland, analysing policies implemented by local government since 2003, followed by a focus on the current ‘Protect Life 2’ (2019) suicide prevention strategy. It will highlight gender inequality in terms of deaths by suicide, which appears to be a gap in current  suicide prevention policies, as male deaths by suicide remain high. Policies that potentially blame and shame men for being reluctant to talk about ‘mental health’ issues have not worked. This review  argues that a proactive approach to preventing male suicide deaths is required, which is focused not only on ‘mental health’ but also solutions to the problems for men that lead to them ending their lives by suicide.

Death by suicide is a serious public health problem in Northern Ireland. Death by suicide is ‘a self-inflicted death’ (O’Connor, 2021: 17). Suicide is complex with genetic, psychological, and environmental risk factors (Joiner, 2005). In an exploration of two leading theories of suicidal ideation, De Beurs et al. (2019:8) found that feelings of ‘perceived burdensomeness’ from the ‘interpersonal theory of suicide’ (Van Orden et al., 2010) and  ‘internal entrapment’ of painful thoughts and feelings from ‘the integrated motivational-volitional model of suicidal behaviour’ (O’Connor, 2011; O’Connor & Kirtley, 2018) were ‘strongly related’  to suicidal ideation. The impact of trauma from violent conflict in Northern Ireland (McLafferty et al., 2016), and the conservative religious nature of society with high levels of homophobia and transphobia (Travers et al., 2020), means that as a result burdensomeness may not just be ‘perceived’ but real, and painful thoughts and feelings like rejection and shame remain trapped internally, for example for loyalist former prisoners (Shirlow, 2014)..

Between 2000 and 2018, 4,783 suicide deaths were registered in Northern Ireland, increasing from 185 deaths in 2000 to 307 deaths in 2018 (Black & McKay, 2019). Since 2005, close association with the deceased has directly affected an estimated 219,000 people (Department of Health (DOH), 2019). Three times as many people die by suicide in Northern Ireland than in road accidents (DOH, 2019). This social policy review will discuss suicide prevention strategies in relation to male suicide deaths in Northern Ireland, analysing policies implemented by the local government since 2003, followed by a focus on the current ‘Protect Life 2’ suicide prevention strategy (DOH, 2019). 

Death by suicide is a gendered issue (Freeman et al., 2017; Struszczyk et al., 2017; DOH, 2019:19; Samaritans, 2020). In 2019 suicide rates globally were 2.3 times higher in males than females: 12.6 per 100,000 for males and 5.4 per 100,000 for females (World Health Organization (WHO) 2021). In 2019 in Northern Ireland, suicide rates were 19.4 per 100,000 for males compared to 6.3 per 100,000 for females (Samaritans, 2022). In Northern Ireland, men are three times more likely to die by suicide than women (DOH, 2019:17,19; O’Neill & O’Connor, 2020; Samaritans, 2020; Black, 2021). From 2000-2005, 83.3% of deaths by suicide in Londonderry were male, with rising unemployment and divorce rates and substance misuse contributory factors (Burns et al., 2008:156). From 2005 to 2011, 77% of 1,671 deaths by suicide in Northern Ireland were male, and 23% were female (O’Neill et al., 2016). 

A steady increase in male suicide deaths in Northern Ireland has been evident since the late 1990s (Department of Health, Social Services and Public Safety (DHSSPS), 2006). Comparing average deaths by suicide in 1984-1993 and 1994-2002 revealed that ‘female suicide rates decreased by 17%, male suicides increased by 13.2%’ (Largey et al., 2009). Research and reports stress that women are more likely to ‘attempt suicide’ (O’Neill et al., 2014; O’Neill et al., 2016; Black, 2019; Black, 2021:17), and men are reluctant to talk about mental health and help-seek (O’Neill et al., 2014; DOH, 2019:19). However, even when men do seek help, they are still at higher risk of death by suicide. For example, just over 60% of the 118 deaths by suicide from 2008 to 2011 of crisis line ‘Lifeline’ clients were men, ‘compared to 42% of Lifeline service users generally’ (Ramsey et al., 2018).  Research of the effectiveness of crisis helplines suggests that it is not so much that men are reluctant to talk but that there may be ‘gender bias’ in telephone crisis workers, requiring research and education to ensure services are better at responding to the specific suicidal presentations and needs of men (Hunt et al., 2018:4). 

The high rate of male deaths by suicide in Northern Ireland is acknowledged in all the strategies published by the local government since ‘Promoting Mental Health Strategy & Action Plan 2003-2008’ (DHSSPS, 2005). ‘Suicide Prevention’ formed Annex 3 of this ‘Mental Health’ strategy. However, previously mentioned rates of registered deaths by suicide show that the strategy did not reduce deaths by suicide. Rather, a ‘significant increase’ in suicide deaths in 2005 led to the publication of a specific ‘Northern Ireland Suicide Prevention Strategy and Action Plan 2006-2011’ called ‘Protect Life: A Shared Vision’ (DHSSPS, 2006).

The overall aim of ‘Protect Life: A Shared Vision’ was ‘to reduce the rate of suicide in Northern Ireland,’ with a target of ‘by 15%’. None of the ‘key objectives’ specifically mention males (DOH, 2006:19). In the ‘Action Plan,’ males are not included as an ‘Action Area’ in the ‘Population Approach,’ though ‘Children and Young People’ are. Only ‘Young Males’ are included in the ‘Targeted Approach.’ Researching suicide deaths from 2005-2011, O’Neill et al. (2014:468) highlight that ‘whilst suicide prevention efforts typically target the young, the average age of the individuals in this population was 40 years and the rates of suicide were highest in those aged 20–50 years.’ Even though deaths of males generally, not just ‘young males,’ had consistently been three times higher than females for many years (Largey et al., 2009), this is not mentioned in ‘Protect Life 1’. More vulnerable ‘not young’ males are not specifically targeted. This could be because older males are assumed to be included in ‘Action Areas’ like ‘High Risk Occupations’ and ‘Prisoners’ (DHSSPS, 2019:35). However, there was no mention of the gender inequality evidenced by male suicide death rates. As previously highlighted, male suicide deaths in Northern Ireland increased at more than three times the rate of female suicide deaths (Largey et al., 2009).

Four years after the publication of ‘Protect Life: Shared Vision’ suicide rates in Northern Ireland reached the highest ever total of 313 registered deaths by suicide in 2010 (NISRA, 2011: 28; . The ‘15% by 2011’ reduction target aim had not been achieved (Black & McKay, 2019). In 2012, ‘Refreshed Protect Life: Shared Vision’ for 2012-2014 was published (DHSSPS, 2012). This acknowledged that males accounted for over three quarters (77%) of the 1,288 deaths by suicides in Northern Ireland between 2005 and 2009 (DHSSPS, 2012:50, 84), and ‘males are three times more likely to die by suicide than females’ (DHSSPS, 2012:81). The strategy placed renewed emphasis on the vulnerability of young males, and highlighted ‘learning’ which encouraged ‘greater focus on males from deprived areas’ (DHSSPS, 2012:27) . This reinforced  the negative impact of poverty on mental health and the increased suicide risk linked to socio-economically deprived areas being worst affected by the violent conflict of ‘The Troubles’ (O’Connor & O’Neill, 2015). A revised action plan included: ‘Objective 6: Enhanced outreach services for males at risk of suicide in deprived areas’ (DHSSPS, 2012:37) and ‘Implementation of a targeted information and awareness campaign for young males’ (DHSSPS, 2012:44). ‘Protect Life: Shared Vision’ (2012) raised awareness that for men the term ‘mental health’ was associated with ‘stigma and stereotyping’ (2012:31), particularly in rural areas, and that research from the ‘Men’s Health Forum’ suggested ‘mental fitness’ as a better term (2012:72).  There was also mention of ‘a male culture of not sharing feelings’ (2012:69), which might be considered victim-blaming in the light of research associating adverse childhood experiences with suicidality (Dube et al., 2001; Bruffaerts et al., 2010).

In ‘Refreshed Protect Life: Shared Vision’ (2012), there was an emphasis on the high numbers of deaths of the “single” marital status group’ (DHSPPS, 2012:52, 55), but this does not account for the higher risk proportionally of other ‘marital status’ groups. For example, O’Reilly et al. (2008) identified that separated/divorced males were three times more likely than married/cohabiting males to complete suicide. Corcoran and Nagar (2010), researching ‘Suicide and Marital Status in Northern Ireland’, also demonstrated that divorced men and women were three times more likely to die by suicide than married persons and that divorced young men aged 20–34 years old were at highest risk.

Tomlinson (2007:116) had drawn attention to the need for more research into groups involved in the conflict in Northern Ireland, including police, emergency services and British Army personnel, paramilitaries and ‘ex-prisoners.’ Tomlinson (2007:80) also cited sociological literature which argues that it is not ‘deprivation’ that causes high suicide rates but ‘social isolation that often accompanies aspects of deprivation.’ O’Reilly et al. (2008) argued that ‘individual and household factors’ like relationships and connectedness were more significant than deprivation, concluding that ‘differences in rates of suicide between areas are predominantly due to population characteristics rather than to area-level factors, which suggests that policies targeted at area-level factors are unlikely to influence suicides rates’ (2008:110) significantly. This raises question about why the new aim of the ‘Refreshed Protect Life: Shared Vision (2012) strategy was ‘to reduce the differential in the suicide rate between deprived and non-deprived areas’ (DHSPPS, 2012:35).

In 2019, ‘Protect Life 2: A strategy for Preventing Suicide and Self Harm in Northern Ireland 2019-2024’ was published (DOH, 2019). This current strategy has two aims: ‘Reduce the suicide rate in Northern Ireland by 10% by 2024’ and ‘Ensure suicide prevention and support are delivered appropriately in deprived areas where suicide and self-harm rates are highest’ (DOH, 2019:11).  The first stated principle of the strategy is to ‘be evidence-based where possible, achieve measurable outcomes and be fully evaluated.’ (DOH, 2019:12). There is much description in the strategy about who is impacted by suicide, who is at risk of suicide, and who accesses services but little evidence of what ‘delivered appropriately in deprived areas’ actually means from critical research and the effectiveness of what has been delivered since the original ‘Protect Life: A Shared Vision’ was published in 2006. 

The opening line of ‘Chapter 2: Strategy Aims, Principles, Scope and Objectives’ is: ‘Protect Life 2 seeks to build on the achievements of Protect Life since it was originally published in 2006’ (DOH, 2019:11). However, the ‘achievements’ of Protect Life (DHSSPS, 2006) did not contribute to any significant reduction in suicide death rates; the strategy aim was not achieved (Black, 2021). Rondon-Sulbaran et al. (2012:106),  exploring the impact of social exclusion amongst young men in Northern Ireland, raised a concern about the evidence base (NSRF & DHSSPS, 2010) for Protect Life (DHSSPS, 2006) and therefore the continuing effectiveness of the strategy. This raises an issue of the evidence-base for the efficacy of ‘Protect Life 2’ in reducing the rates of male death by suicide and proactively addressing gender inequality (Freeman et al., 2017), where male rates of suicide continue to be three times greater than female rates (O’Neill & O’Connor, 2020:538; Samaritans, 2020). 

The terms ‘males’ or ‘men’ are not used in the ‘Aims’, ‘Principles’, ‘Objectives’, ‘Action Grid’, nor the ‘Action Plan’ of the  ‘Protect Life 2’ strategy (DOH, 2019: 11, 12, 16, 56-61). Rather than being listed as a priority, ‘engaging men in suicide prevention’ is described as ‘a challenge’ (DOH, 2019: 46). The main emphasis is on males needing to seek help for mental health difficulties rather than on strategies which specifically and proactively target high risk groups of males like middle-aged men (Struszczyk et al., 2017; Samaritans, 2020). The continued emphasis on ‘promoting help-seeking behaviour, especially in males’ could stigmatise and even shame males, rather than prioritizing the creation of services that men want to and are content to access.  In an exploration of ‘help-seeking prior to male suicide’, Oliffe et al. (2022:1) highlight three significant dimensions which include not just males ‘concealing the need for help’, but also ‘ineffectual’ systems and services, which contributed to the hopelessness of ‘overwhelming illness that couldn’t be helped’. In Protect Life 2 (DOH, 2019:19), under ‘Gender and suicide’, evidence for higher suicide death rates for men includes ‘cultural perceptions of masculinity’. Seemingly men are blamed for not help-seeking as: ‘psychological distress is perceived by many men as a weakness and as representing a loss of control, whilst seeking support equates to an acknowledgement of vulnerability’ (DOH, 2019:19).  Arguably, if men see current services as for the ‘vulnerable’ then services need to be improved to reinforce a ‘strengths-based approach’ (DOH, 2019:20), and also men need to be convinced that the services on offer are what they need and will actually help.  In a systematic review of masculinity and men’s help-seeking for depression, Seidler et al. (2016: 106) highlight that ‘men prefer collaborative interventions involving action-oriented problem solving.’

In ‘Protect Life 2’, males are held responsible for not receiving help as ‘males can be reluctant to disclose health concerns to their GP’ (DOH, 2019:19) which raises questions about trust and congruence. ‘Risk Factors’ (DOH, 2019:27) do explicitly mention ‘working-age men’ and ‘males in unskilled occupations and trades’ but this is not followed through with an ‘action.’ Crucially, under the heading ‘Support for those not known to mental health services / engaging men in suicide prevention’ (DOH, 2019: 46) it is acknowledged that ‘the vast majority of the people who die by suicide but who are not known to mental health services are males aged from their late teens to late 50s.’ Mallon et al. (2019) highlight ‘the limitations of primary care in suicide prevention’ for men. In the earlier ‘Protect Life: Shared Vision’ local research from the ‘Men’s Health Forum’ stated that ‘mind fitness’ was a better term for men than ‘mental health’ and language used should be ‘positive/solution focused’ (DHSSPS, 2012: 74). If the current  strategy (2019) could possibly stigmatise and make men feel shamed for not seeking help for ‘mental health concerns’ with primary care or ‘mental health services’, then it is unlikely to reduce the gender inequality of male suicide death rates in Northern Ireland.

The ‘necessary step’ of ‘community outreach programmes into non-health settings’ for men (DOH, 2019:46; Jordan et al., 2012) needs to be focused on the life issues that contribute to some men ending their lives by suicide, which men themselves may not regard as ‘mental health’ issues. O’Neill et al. (2016:13) produced the ‘first profile of deaths by suicide in Northern Ireland’, concluding with the need ‘to target people who have difficult life experiences in suicide prevention work, notably men, people with employment, financial and relationship crises, and those with mental disorders.’ In 2012, ‘Samaritans’ (Wylie et al., 2012) published nine recommendations based on research to ‘reduce suicide in disadvantaged men in mid-life’. It is not possible to determine if ‘Protect Life 2’ has been effective in implementing them. However, arguably the first recommendation to: ‘Ensure that suicide prevention strategies include explicit aims to reduce socio-economic inequalities and gender inequalities in suicide’ (Wylie et al., 2012:3) has not been met.

Research on the impact of relationship difficulties for men (Uggla and Mace, 2015; O’Neill et al., 2017) also highlights the need to take seriously the recommendation to ‘recognise the profound role of social disconnection in the suicide risk of men in mid-life, and support men to build social relationships’ (Wylie et al., 2012:3). This includes recognition that for some men being ‘disrespected,’ shamed’ or ‘dishonoured’ by their partners and not having contact with their children contributes to death by suicide in some men (Wylie et al., 2012:2). ‘Divorced men have more thoughts about suicide than divorced women; separated men are twice as likely as separated women to have a suicide plan’ (Samaritans, 2012:4). Finally, O’Neill and O’Connor (2020:544) highlight the need for more research into deaths by suicide in the criminal justice system.  Male prisoners are three times more likely to die by suicide than men in the general population, and males released from prison are eight times more likely to die by suicide in the first year of release (Samaritans, 2019). 

If ‘Protect Life 2’ is ‘Refreshed’ then Rodriguez-Otero et al.’s (2021) critical analysis of suicide prevention strategies that place the responsibility on the individual who has a ‘problem’, or a ‘disorder’ should be taken seriously. Questioning ‘the social’ in the ‘biopsychosocial model of suicide prevention,’ Rodriguez at al. (2021:5) conclude that ‘universal suicide prevention should be expanded beyond anti-alcohol policies, awareness campaigns, restriction of lethal means, and work with the media.’ Society needs to change to reduce death rates of men by suicide. 

Suicide is complex and continues to be a serious public health issue in Northern Ireland for both males and females, with the suicide death rate (standardised for age) on a general upward trajectory for both genders since 2019 (NISRA, 2022).   However, appraising suicide statistics and local government suicide prevention strategies since 2003, this review has highlighted the clear gender inequality related to deaths by suicide. In Northern Ireland, three times more men than women have died annually for at least the last several decades (Black & McKay, 2019). Local government suicide prevention strategies in Northern Ireland since 2003 have not successfully addressed this inequality as male deaths by suicide have not been significantly reduced (NISRA, 2022). Whilst all men are uniquely complex, an overall emphasis on men seeking help themselves for ‘mental health’ problems has not worked. A proactive ‘men-seeking’ approach is required, targeting men struggling with social connection, relationship issues and internal entrapment (O’Connor, 2011), which relieves ‘perceived burdensomeness’ (Joiner, 2005), rather than stigmatizing and shaming men by placing the responsibility on men to seek help from services that may not actually be effectual for men (Seidler et al., 2016; Mallon et al., 2019; Oliffe et al., 2022).  An explicit suicide prevention strategy aim to prevent male deaths by suicide is required, rooted in evidence-based research on men’s needs and what actually works for men, and including an in-depth evaluation of the effectiveness of current publicly funded suicide prevention initiatives, particularly those in deprived areas. 

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