Male suicide a growing concern in tough times

Suicidal men tend to share certain characteristics: They feel trapped in their lives. They're commonly substance abusers. Depression, bipolar disorder, and schizophrenia are highly correlated with suicide risk.

But there are still miserable men with no desire to check out early, thank you, and others who seem well adjusted but who flirt in their minds with suicide. Psychotropic drugs that dampen depression don't always douse a death wish.

"I think every man is capable of reaching a desperate place where suicide can move onto his psychological radar screen," says Jobes. "But who goes there, when, how, and why is this unique interplay of biochemistry, social forces, family modeling, and other factors. How those queue up is remarkably complex and specific to the man who's struggling at that moment. "I'd always thought of suicide as a tragedy primarily affecting two groups of men: adolescents, for whom upheavals that would seem manageable soon enough instead become matters of life and self-inflicted death; and the aged, who might feel miserably alone or who simply can't stand the thought of another day of nursing a hurt that's been aching all their lives. There's a reason for that misperception.

"Several years ago, colleagues of mine organized a National Institute of Mental Health conference on suicide and middle-aged men, and there was sort of a ho-hum reaction," says Jobes. "Like, who cares about those guys? Most suicide prevention focuses on subgroups, whereas few seem to notice the 800-pound gorilla."

"Men in the overall U.S. population just haven't been the focus of a lot of suicide-prevention efforts," adds Kerry L. Knox, Ph.D., director of the Canandaigua Center of Excellence for Suicide Prevention of the U.S. Department of Veterans Affairs. That's mind boggling, since 70 percent of all suicides by men occur in life's prime, not its dawning or twilight. Suicide rates are comparatively low under age 16, rise gradually through age 18, and then jump through age 24; the normal four-to-one male-to-female ratio of suicide deaths rises to seven to one between the ages of 20 and 24. But rather than tumbling after age 24, the rate actually levels off at the high point. One cause of the spike is that mental disorders often tighten their grip in a man's early 20s.

"[Patients with] bipolar disorder and schizophrenia have a higher risk of suicide during the first 5 years of the disorder rather than later on, when people often have learned to accept it and deal with it," says Firestone.

Recognizing psychological land mines
These individuals are usually prescribed drug regimens, which can help if they remember to swallow all of their pills. But that's a tacit admission of mental illness, one that's often resisted. In rare cases, taking mood-altering drugs can make a bad situation worse. Even if a man reaches his 20s in good shape, psychologically speaking, suicide land mines — like the ones mentioned below — remain scattered along the journey throughout his 30s and 40s.

Relationships: Joiner estimates that "romantic disruptions" and other relationship issues trigger depressive episodes in about 75 percent of men between the ages of 20 and 40 who commit suicide. "Especially in their early 20s, guys can think,This one person was right for me, I've lost her, and it's all over," Firestone says. "They lack the perspective that they're going to have other relationships, maybe even better relationships, in the future."

Career Failure: Data going back decades shows that, like clockwork, economic downturns push more men over the brink — a fact that should concern us all now. Men draw much of their identity from their careers, and when unemployment rises, that underpinning falls away. Many men at that highly vulnerable age for suicide — the early 20s — may struggle simply to begin a fulfilling career in a sharp economic downturn. The feeling of being a burden doesn't apply only to people failing at life. Even the most successful, driven men, the ones we perceive as being on top of their game, can buckle under a heavy load.

Which might explain why Tennessee Titans quarterback Vince Young was reported to have mentioned suicide to a therapist earlier this season. "With so many people identifying with and riding on his success, the burden of failure can loom large," says John Draper, Ph.D., director of the National Suicide Prevention Lifeline program. The higher the stakes, the more there is to lose.

Shame and Humiliation: It's one thing to fall from grace; it's another to have that fall subjected to public display and ridicule. That prospect was a major contributor to "executive suicides" such as those committed by Clinton lawyer and confidant Vince Foster, and Enron vice chairman Cliff Baxter. Fame isn't a prerequisite, either; going public can mean having your own family and social circle learn embarrassing news. "There's this very male lineage of suicide being a face-saving way of resolving dire circumstances," says Jobes.

Modern Warfare: Historically, suicide rates among soldiers have dropped "in theater" during times of actual combat, but that trend has been turned on its head in Iraq and Afghanistan: The number of suicide attempts in the U.S. Army has increased sixfold since the war on terror began. Nearly 600 soldiers in that military branch alone — the size of an infantry battalion task force — have died by suicide. The Army itself estimates that up to 11,600 times during that span, an Army soldier has attempted to harm or kill himself. That doesn't bode well for returning veterans, who are at heightened risk for suicide once they leave the structure of military life.

When Mark Kaplan and colleagues used national health surveys to track 320,890 men for 12 years, they learned that the veterans in that group were no more likely than the others to die from natural causes or by accident — but twice as likely to die by their own hand. Recent reports suggest 1,000 suicide attempts per month among V.A. vets, a total that the V.A. spokesperson I interviewed wouldn't dispute.Self-preservation is our most basic instinct, so suicidal people must be mentally ill, right? Not necessarily. Joiner believes men learn fearlessness every time they play a contact sport, fight in a bar, or experience pain or injury. This eases the brakes that stop us from doing something contrary to our nature. Sometimes, that includes killing ourselves.

A Deadly Side Effect According to prescribing info, these drugs are potentially linked with suicidal thoughts. (If you're on a drug and feeling down, consult with your doctor before discontinuing it.) Neurontin Last July, an FDA panel announced that this and 10 other anti-epilepsy drugs double suicide risk. Antidepressants Prozac, Paxil, and Zoloft sometimes work like magic. But the FDA concluded in May 2007 that everyone ages 18 to 24 on an anti-depressant is at a small but increased risk of developing a drug-induced urge to die. Accutane Pimples may be the least of your problems if you take this acne med: The FDA has linked it to dozens of suicides. Interferon No wonder some patients who take this drug for hepatitis B and C or cancer want to hurt themselves. The side effects are a cocktail for suicidal behavior. Amantadine This drug, used to treat Parkinson's syndrome and influenza infections, has a list of side effects that include depression and suicidal thinking. Amphetamines This class of drugs includes Ritalin and Adderall, used to treat attention-deficit hyperactivity disorder, but could exacerbate preexisting depression or bipolar disorder. Reglan If heartburn weren't bad enough, this acid reflux drug has been reported to trigger a death wish in some users. Chantix Last February, the FDA reported that this stop-smoking pill gave a small number of users "vivid, unusual, or strange dreams" — and thoughts of ending it all.

To test his theory, Joiner asked student-subjects to fill out self-reporting questionnaires on how much pain they could withstand. Male subjects scored higher, and it wasn't just frat-house bravado. When participants were then asked to place their forearms in water barely above freezing or have their fingers pinched by a mechanical device, men lasted longer than women did. At the suicide conference I attended, researchers presented the results of an experiment that tested Joiner's theory on recent veterans of the Iraq war.

Never is "learned fearlessness" so prevalent as it is during the violence of combat, and the participants did report becoming more tolerant of mayhem and danger. "When I was overseas, I kind of lost connection with reality... and my feelings," said one subject. "If you don't have any emotions, you aren't scared or afraid, either."

If Joiner is right, many of these vets will be at high risk of harming themselves, perhaps fatally, as civilians. Learned fearlessness is particularly dangerous when it's combined with the feeling of being a burden to others.

"Those pieces — isolation, fearlessness, and feeling like a burden — simultaneously lead to suicidal behavior," says Joiner. "You think, 'my death will be worth more than my life to people I love.' "From study reviews, suicide experts find that isolation usually emerges as the biggest risk factor of all. Jobes has seen this dynamic unfold among soldiers. But when men do reach out, they can regain their footing quickly. "Once you pull them out of that internal world, they respond well to a two-heads-are-better-than-one approach to problem-solving in therapy," says Jobes. "But it's a conundrum because they're not seeking treatment."

For a man who tried to kill himself, John Kevin Hines is pretty lucky. On his descent from the Golden Gate Bridge, he threw his head back during free fall, which allowed him to hit the water in a seated position — albeit at 75 mph. He opened his eyes as he plunged 50 feet, and as it became darker, he thought, I didn't die. What am I going to do now?

A man who moments ago tried to kill himself was desperately fighting for his life now. He broke through the surface just before passing out. At the moment he jumped, a woman who had a Coast Guard friend on speed dial just happened to be driving over the bridge — which is the only reason two Coast Guard members fished Hines out of the water.

"Do you know what you just did?" one of them asked."Yeah, I just jumped off the Golden Gate Bridge." "Why?" "I don't know," said Hines. "I guess I wanted to die." "Do you know how many people we pull out of this water who are dead already?"

Of course, the best way to prevent suicide is to keep men like Hines off those bridges in the first place. In 1996, John Draper founded a crisis hotline for the Mental Health Association of New York City. Three years after gaining national attention for its work surrounding 9/11, the organization won a grant to run the national network of suicide hotlines. Every month, the network's 133 independently operated call centers receive more than 40,000 calls. A recent study in the journal Suicide and Life-Threatening Behavior found that when people call a hotline they experience a decrease in hopelessness and psychological pain (but no reduction in intent to die). The effect lasts for weeks afterward. Twelve percent of callers said the hotline kept them alive.

"Sometimes when a man's mind is locked in to suicide, there's a paradoxical openness, too," says Draper. "If you're open to killing yourself, might you be open to less absurd notions as well? They just have to stay alive long enough to find other options."

Another sobering truth is that a prior attempt makes you more likely to eventually kill yourself. But Draper turns that upside down. "Past attempts carry a lifetime risk estimated at about 7 percent," he says. "That means 93 percent of those who attempted suicide found ways to survive periods when they were convinced life wasn't worth living and to go on to live out their lives. What might they have missed otherwise?"

Back From The Brink
Leading suicide expert Lisa Firestone, Ph.D., director of research and education at the Glendon Association, details suicide's progression, and how to halt it.

1. Losing interest in school, work, or hobbies
"A male friend won't tell you he's sad, but he will tell you if he's lost interest in his hobbies," says John Draper, Ph.D., director of the National Suicide Prevention Lifeline. "Disruptions in those areas are real signs."
What he's thinking: What's the use? My work doesn't matter anymore. Why bother even trying? Nothing matters anyway.
Warning signs: Decreased work or academic performance, giving up hobbies or other previously enjoyed activities.
Don't: Cajole or demean. Nor should you assume that this is just a slump, and wait for things to pass.
Do: Gently but persistently point out that he may have a problem, and that treatments are readily available.

2. Directing hatred toward himself
"Tearing oneself apart creates the psychological pain and desperation that drive the suicidal person," says Firestone. "Suicide becomes a way to escape the pain and aggravation." I'm incompetent, stupid.
What he's thinking: I'm ugly, disgusting. I'm a fool, a creep, a reject. I don't deserve anything; I'm worthless.
Warning signs: Statements of helplessness, extreme psychological pain, desperation, increased irritability and anger.
Don't: Judge, turn away, or otherwise feel that these are feelings "real men" shouldn't have or talk about.
Do: Listen. Allow him to express his feelings. Offer him a more com- passionate evaluation of himself.

3. Feeling like a burden to family and friends
"I've had patients insist in front of their wives, 'No, no, you'll be better off without me,'" says David A. Jobes, Ph.D., a professor of psychology at the Catholic University of America. "Family members don't feel that way."
What he's thinking: See how bad I make everyone around me feel? They'd be better off without me. I'll just stay away and stop bothering them.
Warning signs: Moodiness, lack of communication, lethargy, exhaustion, hopelessness.
Don't: Ask vague questions like, "You're not thinking about doing anything, are you?" This telegraphs disapproval.
Do: Talk openly. Ask, "Are you thinking about killing yourself?" If his answer doesn't sit right, ask him again.

4. Talking about suicidal thoughts
"As simple as it sounds, talking about wanting to die by suicide is a very clear and dangerous warning sign," say Joiner. Unfortunately, that sign is often missed or ignored.
What he's thinking: I'd better plan it. It's the only thing I can do. I have to buy a gun and then find a deserted back road, maybe. Reading or writing about death, reminiscing about a dead person, saying things like, "I might as well be dead."
Don't: Assert that suicide is immoral and leave it there. He desperately needs help. Don't let him reassure you he's fine.
Do: Empathize with the pain but not the solution. Find a counselor. Call the hotline numbers.

5. Initiating his own demise
"People can become so despondent, and yet they hide intentions," says Eric Caine, M.D., co-director of the Center for the Study of Prevention of Suicide at the University of Rochester. "They might tell a doctor they're fine."
What he's thinking: I can't even do this! I've thought about this long enough. Look, I'm miserable every minute. Just end it. It's the only way out!
Warning signs: Preparing a note, a will, or both; giving away prized possessions.
Don't: Be sworn to secrecy. What's more important: his confidence or his life?
Do: Remove means (guns, pills, poisons). Connect him with crisis counselors. Time is running out.

6. Sudden, dramatic mood change — for the better
"In his own mind, he may finally be at peace with his decision — not the decision to seek help, but the one to end it all," says Firestone.
What he's thinking: This is the solution to all my problems. I have made my decision. I am in control now. All this pain will soon be over.
Warning signs: An unexpected, even jarring brightening of his disposition, especially one that doesn't feel natural to you.
Don't: Think, Whew, everything's fine now! I can stop worrying about him for a while.
Do: Ask him to give help a chance — tell him he can always decide to kill himself later. Arrange for help immediately!

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