Selling painkiller tablets in blis­ter packs has helped to re­duce the num­ber of over­doses

Sui­cide is the big­gest killer of men un­der 50. We want to know KH EWTTGPV TGUGCTEJ EQWNF JGNR WU ƂPF C UQNWVKQPe

Focus-Science and Technology - - CONTENTS - WORDS: SI­MON CROMPTON

There are myr­iad sto­ries. Peo­ple who were laugh­ing an hour be­fore they took their lives. Peo­ple who were sim­ply “not quite them­selves”. Peo­ple who had strug­gled with longterm de­pres­sion. Peo­ple who had a his­tory of sui­cide in the fam­ily. Suc­cess­ful peo­ple who seemed to have ev­ery­thing to live for.

They all de­cided to kill them­selves. Of­fi­cial records say that in the UK in 2016, 4,508 men and 1,457 women died as a re­sult of sui­cide, but some ex­perts be­lieve the true numbers may be as high as dou­ble that. Men ap­pear par­tic­u­larly vul­ner­a­ble: in fact, sui­cide is the lead­ing cause of death in men un­der 50 in the UK, claim­ing more lives than car ac­ci­dents, heart dis­ease or can­cer. If it were a new dis­ease, sui­cide would surely prompt a na­tional emer­gency.

The rea­sons so many men take their lives are mys­te­ri­ous and in­finitely di­verse – a com­plex web of so­cial, psy­cho­log­i­cal, bi­o­log­i­cal and cul­tural pres­sures. But new sci­en­tific ap­proaches are pre­sent­ing un­ex­pected av­enues for dis­en­tan­gling the threads. Vir­tual re­al­ity ex­per­i­ments and ar­ti­fi­cial in­tel­li­gence are re­veal­ing those most at risk and could even pre­dict who is most likely to try and take their life. Mean­while, the­o­ries of male ‘so­cial per­fec­tion­ism’ are throw­ing light on why men feel they have failed. To­gether, they of­fer the prospect of bet­ter pre­ven­tion. 2

2 Ac­cord­ing to Prof Rory O’Con­nor, who runs the Sui­ci­dal Behaviour Re­search Lab at the Univer­sity of Glas­gow, changes in so­ci­ety are mak­ing men es­pe­cially prone to the feel­ings of en­trap­ment that seem to be a key driver to sui­cide as a means of es­cape. His lab works with sui­cide sur­vivors in hos­pi­tals and other set­tings, and con­ducts stud­ies in the lab to find links be­tween sui­cide and psy­cho­log­i­cal and so­cial char­ac­ter­is­tics.

Some re­cent work, for ex­am­ple, has ex­am­ined pain sen­si­tiv­ity. There is al­ready some ev­i­dence that one of the rea­sons more men kill them­selves than women is sim­ply that they carry it through more ef­fec­tively, us­ing more lethal means. Work­ing with men and women who had at­tempted sui­cide in a hos­tel set­ting, O’Con­nor’s re­search sup­ports this view. He found that men were less fear­ful about dy­ing than women, and that men have greater abil­ity to with­stand the phys­i­cal pain re­quired to carry out more lethal meth­ods of sui­cide. “There are many things in the mix,” says O’Con­nor. He points out that whereas in the 1990s men in their 20s were the high­est sui­cide risk group, they have car­ried their vul­ner­a­bil­ity with them as they got older, so now it’s men aged 40-50 who are high­est risk. There’s ev­i­dence that this is linked with re­cent changes to male iden­tity in so­ci­ety. “Tra­di­tion­ally the male was the bread­win­ner, pro­vided for the fam­ily, and was de­fined by this ‘job for life’ idea. This has changed markedly in re­cent decades, and men are still strug­gling with that,” he says.

In par­tic­u­lar, men may be strug­gling with some­thing that O’Con­nor de­scribes as “so­cially pre­scribed per­fec­tion­ism”. O’Con­nor’s the­ory is that some men – the so­cial per­fec­tion­ists – are acutely aware of what they think other peo­ple ex­pect of them, whether that be in work, fam­ily or other re­spon­si­bil­i­ties. Men’s so­cial per­fec­tion­ism can be judged us­ing ques­tion­naires ask­ing how far they agree with state­ments such as “Suc­cess means that I must work even harder to please oth­ers” and “Peo­ple ex­pect noth­ing less than per­fec­tion from me.” O’Con­nor has found a re­la­tion­ship be­tween so­cial per­fec­tion­ism and sui­ci­dal­ity in a wide va­ri­ety of pop­u­la­tions, from the dis­ad­van­taged to the af­flu­ent.

“Ac­cord­ing to my model, those who are highly aware of peo­ple’s so­cial ex­pec­ta­tions are much more sen­si­tive to sig­nals of de­feat in the world around them,” he says. “When things go wrong in their lives – for ex­am­ple, if they lose a job, a re­la­tion­ship breaks up or they be­come ill – they are much more af­fected by that.”

Prov­ing such links is not easy. As O’Con­nor says, al­though dev­as­tat­ing, sui­cide is sta­tis­ti­cally-speak­ing a rare event – so cap­tur­ing what leads to it through con­ven­tional re­search re­quires many thou­sands of peo­ple. But US psy­chol­o­gist Dr Joe Franklin, who heads the Tech­nol­ogy and Psy­chopathol­ogy Lab at Florida State Univer­sity, be­lieves he may have found an an­swer to this prob­lem. He is re­ject­ing con­ven­tional sci­en­tific re­search tech­niques, and in­stead prob­ing the causes of sui­cide us­ing vir­tual re­al­ity and a form of ar­ti­fi­cial in­tel­li­gence called ma­chine learn­ing.

“It’s a myth, says men’s sui­cide char­ity CALM, that men don’t want to talk about their feel­ings”

HOW TECH­NOL­OGY CAN HELP

“In ex­per­i­ments, you can’t – for ex­am­ple – so­cially re­ject peo­ple to see whether that makes them more likely to kill them­selves,” says Franklin. “But now we can give [sub­jects] the op­por­tu­nity to en­gage in vir­tual sui­ci­dal be­hav­iours, us­ing vir­tual re­al­ity, and study this in the lab.”

For ex­am­ple, Franklin’s team is in­ter­ested in test­ing a pro­posed link be­tween so­cial iso­la­tion and sui­cide which has un­til now been un­proved. First, they ex­posed their test sub­jects to stan­dard psy­cho­log­i­cal sce­nar­ios de­signed to make them feel mildly so­cially re­jected. Then they put them into vir­tual re­al­ity hel­mets, plac­ing them in a sce­nario where they were stand­ing on top of a high build­ing.

“We said to them: ‘Okay, in or­der to fin­ish the task, you can ei­ther step off the side of the build­ing, or you can press the el­e­va­tor but­ton and ride down to the ground floor. Your choice,’” he says. Sure

enough, some of those who had been so­cially re­jected chose to jump.

Franklin says there’s now good ev­i­dence that this kind of ex­per­i­ment pro­vides a good ‘proxy’ for real sui­cide at­tempts, so it has gen­uine value in study­ing many con­tribut­ing causes of sui­cide. There are po­ten­tially thou­sands of fac­tors that might con­trib­ute at least a bit – and each could be im­por­tant, be­cause Franklin’s team has con­cluded there are no ‘big’ fac­tors can ac­cu­rately pre­dict risk. How­ever, the hu­man brain is in­ca­pable of find­ing pat­terns in such com­plex­ity of causes, be­lieves Franklin. The only way of get­ting to the root of sui­cide causes is by us­ing ma­chine learn­ing.

“You give the ma­chine ev­ery bit of in­for­ma­tion you have,” he ex­plains. “You say: we have these 500 peo­ple who died of sui­cide, and these 500 who didn’t. Here’s 2,000 bits of in­for­ma­tion about them all. Now you sort out the best al­go­rithm for pulling those groups apart.” This sys­tem could be po­ten­tially plugged into na­tional elec­tronic health records, both to find pat­terns of con­trib­u­tors to sui­cide and to iden­tify in­di­vid­u­als’ sui­cide risk.

Amid the com­plex­ity, the data from vir­tual re­al­ity ex­per­i­ments and ma­chine learn­ing is likely to re­veal psy­cho­log­i­cal ‘choke points’, says Franklin, where pre­ven­ta­tive ac­tion may work on many fronts. One pos­si­ble choke point his lab is cur­rently test­ing is the idea of psy­cho­log­i­cally trick­ing peo­ple into believ­ing they are not sui­ci­dal.

“Our data so far in­di­cates that how you con­cep­tu­alise your­self is im­por­tant: if you be­lieve you are sui­ci­dal, you are more likely to en­gage in sui­ci­dal be­hav­iours. So say I gave you a pill that was ac­tu­ally a sugar pill, but I told you one of its side ef­fects was that it made peo­ple less likely to en­gage in sui­ci­dal be­hav­iours,” he says. “Then I tell you that’s par­tic­u­larly true for peo­ple whose pain sen­si­tiv­ity goes down after tak­ing it. Then I trick you into think­ing that your pain sen­si­tiv­ity has gone down. What would very likely hap­pen is that you would stop believ­ing that sui­cide was an op­tion for you. We know the placebo ef­fect is pretty in­cred­i­ble, and if we could just flip that con­cep­tual switch, maybe you’d get a quick and pow­er­ful in­ter­ven­tion.”

There’s al­ready ev­i­dence about the ef­fec­tive­ness of some pub­lic health choke point ini­tia­tives, ef­fec­tively mak­ing sui­cide more dif­fi­cult to per­form. Firearm sui­cide rates in Aus­tralia fell by 57 per cent in the seven years after a gun ban in 1997, and the num­ber of parac­eta­mol over­doses in the UK dropped sig­nif­i­cantly when a limit was placed on the num­ber of tablets each cus­tomer was per­mit­ted to buy (anec­do­tally, the ex­tra ef­fort re­quired to re­move a large num­ber of tablets from the 2

2 now-com­pul­sory blis­ter packs may also have been a fac­tor).

In Detroit, USA, the Henry Ford Health Sys­tem has re­duced sui­cide rates by 80 per cent among ser­vice users di­ag­nosed with de­pres­sion, achiev­ing its aim of zero sui­cides in 2009. Its model in­volves im­prov­ing ac­cess to care, re­strict­ing ac­cess to lethal means of sui­cide such as guns, and hold­ing staff ac­count­able for learn­ing and im­prov­ing after each sui­cide. Health sys­tems around the world are now us­ing the Henry Ford ap­proach as a model to re­duce sui­cides among men­tal health pa­tients.

REACH­ING OUT

O’Con­nor be­lieves such large-scale pub­lic health ap­proaches are im­por­tant, but says if the male sui­cide prob­lem is to be prop­erly tack­led, there need to be gen­der-spe­cific ini­tia­tives. “We need to speak to men and gen­uinely un­der­stand what they need. That in­volves get­ting be­yond re­fer­ring men to clin­i­cal ser­vices, but go­ing to where men are – sports clubs, for ex­am­ple – and pro­mot­ing con­nec­tion, well­be­ing and stress man­age­ment there, though not framed as ‘sui­cide pre­ven­tion’.”

It’s a myth, says men’s sui­cide char­ity CALM, that men don’t want to talk about their feel­ings – they of­ten sim­ply don’t want to share their prob­lems with fam­ily, friends and col­leagues. That’s where con­fi­den­tial and anony­mous helplines such as Sa­mar­i­tans and CALM have a vi­tal role to play.

Clin­i­cal psy­chol­o­gist Martin Sea­ger, for­merly a con­sul­tant for Sa­mar­i­tans, agrees it’s im­por­tant to tar­get ser­vices specif­i­cally to men, and ad­vo­cates men-only dis­cus­sion groups across the coun­try. “In sin­gle-sex groups men can be very bloke-y one minute, then talk about some­thing in­cred­i­bly painful the next. If men are alone in a room they are tremen­dously good at sup­port­ing each other.”

An­other way of help­ing men ex­plore their feel­ings with­out in­volv­ing those close to them is via tech­nol­ogy. Franklin’s team has de­vel­oped an ex­per­i­men­tal mo­bile app that in­creases aver­sion to sui­cide and pro­motes feel­ings of self-worth via a sim­ple as­so­ci­a­tion game avail­able on iOS called Tec-Tec. Early tri­als are en­cour­ag­ing. An­other Amer­i­can psy­chol­o­gist, Robert Morris, is tri­alling a web­site which pro­vides peer sup­port for peo­ple with de­pres­sion and helps users re­assess neg­a­tive thoughts us­ing cog­ni­tive be­havioural ther­apy.

O’Con­nor is work­ing with researchers at Vrije Univer­siteit Am­s­ter­dam on a smart­phone app that will help high-risk men mon­i­tor feel­ings of en­trap­ment and sui­ci­dal­ity. He be­lieves that tech­nol­ogy un­doubt­edly has a role to play. “But we need to get ev­i­dence first,” he says. “If we can demon­strate that an ap­proach is ef­fec­tive in a clin­i­cal trial, then you can use an app-based ap­proach to broaden its reach to ev­ery­one.” Si­mon Crompton is a sci­ence jour­nal­ist and for­mer health editor for both The Times and The Daily Tele­graph.

LEFT: Dr Joe Franklin is us­ing vir­tual re­al­ity to find out more about causes of sui­cide

BE­LOW: Fol­low­ing the Na­tional Firearms Buy­back Pro­gram in Aus­tralia, more than 660,000 guns were taken out of pub­lic hands, and sui­cide by firearms de­creased dra­mat­i­cally

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