By Dr XAND van TULLEKEN
Eight in ten suicides are among men. Now a renowned TV doctor — who admits to harbouring his own deep-seated anxieties — passionately argues . . .
AS A young doctor in my 20s, I saw lots of men come through the doors of A&E after trying to take their own lives. At the time, I found the very idea of suicide baffling and self-indulgent. But as I got into my 30s, I began to experience the crushing weight of ever-intensifying life pressures, at work and at home. I developed a dreadful sense that everything was out of control.
Lots of things have happened in my life. I’ve messed up relationships and have a son who lives thousands of miles away. I worry about him, about money, about my career.
I don’t feel critical of my younger self — in many ways, I wish I could return to the days when optimism and joy seemed reasonably effortless.
But all the things that have happened in the years since make me relate to thoughts of suicide quite differently now.
Because, in truth, there have been challenging moments where it has become a possibility to me — when I’ve thought about it.
These thoughts are not always present, and they aren’t often severe or dramatic. I have not been diagnosed with depression, nor do I take any medication, and it is hard to know how common my experience is.
But while we tend to assume suicidal thoughts are incredibly rare, in fact, there is data to show that I am similar to the majority of men. No, I have never planned anything, but my own death has sometimes felt as if it would be a good way to escape my pressures.
I vividly remember being on a plane and thinking, well, if it crashed, that would be no bad thing. Of course, the plane landed safely and the thoughts evaporated. I felt glad to be on the ground and on my way to see friends and family. But the experience has brought me to the powerful realisation that no one is immune from suicidal thoughts.
According to the statistics, 79% of suicide deaths in Ireland last year were among men and the highest rates of suicide were observed among men aged 45 to 54. This high male to female ratio has remained a consistent feature of deaths by suicide.
That is in part because men are far less likely to seek help than women when troubles become too much to bear. Men also often have smaller networks of friends on which to rely, making each person in a man’s life potentially much more important.
In my 20s, I had lots of friends and colleagues. But now I’m 40, it doesn’t feel the same. You wouldn’t have to remove many people from my life to leave me pretty isolated. Like many men, I also sometimes find it extremely hard to ask for help.
I’m very lucky to have a couple of friends who persistently phone or text, even if I ignore them. It becomes much easier to turn to someone when things aren’t going well if they make themselves available — and offer conversation, not judgment.
Frequently I hear people saying that ‘men must learn to talk’, but in discussing and writing about this topic, I realise again and again how difficult it is to properly explain my thoughts to anyone else.
It is exhausting and frightening and you risk — or feel you risk — humiliation and judgment, or blank incomprehension. This is why it is so important to reach out, and to make sure people who you think are struggling know you are there and know you are thinking of them.
They may not take you up on your offer of a chat, you may feel ignored, but the support messages do get through and make a difference.
THE difficulty is that the state of mind many men are in when their thoughts turn to suicide makes it extremely hard for them to make the first move, to reach out. It makes me wonder how many men I know might be struggling in the same way.
What I know for certain is that I have lost more friends to suicide than to anything else.
One was an academic superstar, newly married with a vast capacity for joy and fun, whose death came suddenly and violently. It is hard to describe my reaction to the news — I think mainly terror that, if this could happen to my brilliant friend, it could happen to me.
Another friend pulled back from the brink only after phoning his lifeinsurance company to ask if it would pay out to his family — and solve their financial problems — in the event of his suicide.
The fact that it wouldn’t pay made him reconsider.
Stories like these made me determined to find out how we can change things.
Surely we have to try, for even in dry financial terms the effort makes perfect sense: there are three potential economic costs associated with suicide, including lost market output and a range of other cost factors.
But the real hurt cannot be counted in cold cash — as Steve Mallen, who lost his son in February 2015, can testify. Edward was only six weeks past his 18th birthday when he took his own life at a railway crossing. Head boy at his school, he had been offered a place at a prestigious university.
Steve told me that being given the terrible news ‘was as if someone had opened the door and thrown a hand grenade into our house. It was like staring into an abyss of grief’.
Two weeks earlier, Edward had told his GP about his suicidal thoughts. His doctor had said the boy should be seen by mental health professionals within 24 hours. But when assessed he was deemed not to be at significant risk. His family were not told of Edward’s troubles.
‘We should not underestimate the catastrophic scars suicide leaves on society,’ Steve told me. ‘Time does not heal. You just learn to manage.’
The medical body responsible has admitted things ‘could have been done better’. Indeed, we must all try to do better, for ourselves and for each other, to stem this lethal tide.
There were 392 suicides recorded in Ireland last year but it is worth noting that some suicides might not be registered as such, so the actual number of deaths could be higher. Then there are an estimated 12,000 attempted suicides each year, and these are only the people who actually act on their suicidal thoughts.
National statistics point to three major factors: bereavement, relationship breakdown and financial pressure. Research shows that those in the lowest economic groups are at ten times higher risk of suicide than those in the top 10% most affluent areas.
Men, for all their bluff image — in fact, partly because of it — are highly vulnerable after a relationship breakdown. ‘In general, men invest a lot more emotional support in their partners than women do,’ Professor Rory O’Connor, a suicidal behavioural expert, told me.
‘If their relationship breaks down, that man is potentially isolated because they don’t tend to have the broader network of emotional support that women have.’
Another problem is that none of these risk factors helps health professionals to predict who is likely to act on those thoughts.
Statistical studies demonstrate that no one factor — or even one small group of factors — can predict someone’s risk of suicide much better than a coin-flip.
It’s a familiar dilemma for any doctor. There are few things more nerve-racking in medicine than trying to figure out, once you think someone is at risk of killing themselves, whether you should let them leave the hospital or not.
Of the six weeks I spent doing psychiatry during my training, I remember only the same conundrum: was this person safe to leave?
Almost everyone we saw posed a threat to themselves or others. But we didn’t have the resources or — rightly — the confidence in our own judgment to section more than a tiny fraction.
Devoting time and research to this problem could lead to huge breakthroughs in how we understand the risk of suicide.
Dr Joseph Franklin, an assistant professor of psychology at Florida
State University, believes he may have cracked this problem using highly sophisticated mathematics. His team looked for a way to understand up to 800 different suicide risk factors at a time, to see which combinations were most dangerous.
They considered information such as age and gender, and mental and physical illnesses.
To analyse the data, they used ‘machine-learning’ algorithms, which crunch numbers in ways far more complex than the human brain can compute.
Dr Franklin told me: ‘We are now able to predict non-fatal suicide attempts and suicide deaths with about 90% accuracy a few years before it happens.’ It might sound macabre, but looking at complex combinations of factors rather than single ones could revolutionise how we intervene in suicidal behaviour.
If we applied this machinelearning to the HSE database, with its millions of detailed patient records, we might be able to save thousands of lives.
However, as a doctor, I fear that putting high-risk decisions about patients’ lives into the hands of a machine would be very difficult for health professionals to accept. The ethical implications are complex and, for many, terrifying.
What else can we try? American doctors are pioneering another way to reduce suicide. In Detroit, a city with huge unemployment, high crime rates and extreme poverty, doctors at the Henry Ford Health System aimed to completely eliminate suicide among patients.
A zero-suicide rate sounds wildly unrealistic. But Dr Cathrine Frank, who heads the department of psychiatry and behavioural health services there, says: ‘If it’s not zero, what is the goal?’
And some years they actually hit their target. ‘Since we introduced the policy in 2001, our suicide rate decreased by 80%. We even had some years where it was zero,’ she adds. To achieve this, the team changed their approach entirely.
First and foremost, they started talking about suicide more. They asked primary-care doctors to screen patients for suicidal thoughts whenever they saw them, regardless of what they had come in for. Each patient at risk was referred for care, whether that was talking therapy, medication or someone visiting their home to remove firearms.
I sat in on a consultation with a patient who had originally come to the hospital for tests for his bowel condition, Crohn’s disease. However, when asked about suicidal ideas, he admitted he’d had dark thoughts. Hospital psychiatrists helped him to draw up a safety programme, including strategies for talking to loved ones.
Connecting for Life, the national strategy to reduce suicide over the five-year period of 2015 to 2020, has set a target of cutting the suicide rate in Ireland by 10% by 2020. I think this is vastly under-ambitious, and aiming for zero suicide seems far better.
Steve Mallen, who lost his child so painfully, is developing an initiative called the Zero Suicide Alliance, launched last November.
It aims to bring the zero-suicide goal to the health service, schools and emergency services.
However, the story of Detroit really shows that you don’t have to be a health professional to help. We can all change things by communicating better, talking more — and by asking the people around us specifically about suicide.
BUT to give real help, we men have to start talking openly about this great modern taboo. And it is a huge taboo.
Nevertheless, broaching this subject can make the difference between life and death.
‘Evidence shows asking someone if they are suicidal can actually protect them,’ Professor Rory O’Connor explains. ‘They feel listened to. Their feelings are validated and somebody cares about them. Reaching out in a moment of crisis can save a life.’
Reflecting on this, I realised that every once in a while, my twin brother Chris phones me and, amid the conversation, asks: ‘You aren’t going to kill yourself are you?’ It’s light-hearted, almost a figure of speech, and doesn’t feel significant or abnormal.
So recently, using the BBC film that I was making as an excuse, I returned the favour. I called him, explained what Professor O’Connor had said, and asked if he’d had any thoughts about suicide recently.
When we spoke about it afterwards, Chris simply said it had been good to hear that someone close to him was thinking about him.
We can all turn to the person next to us or phone a mate and ask them, not only whether they are doing OK, but whether they are having thoughts about killing themselves. You could save a life — even though you may never know it.
People sometimes ask me: ‘What if the person says yes? What should I do then?’ There’s no perfect answer — but you can find a way to help, and it’s so much better than not trying at all.
In the fight against suicide, the power of a single conversation should not be underestimated.