Preventing Suicide among
Men in the Middle Years:
Recommendations for
Suicide Prevention Programs
TABLE OF CONTENTS
ACKNOWLEDGEMENTS 3
INTRODUCTION 5
SECTION 1 7
Understanding Suicide among Men in the Middle Years: Key Points
SECTION 2 12
Recommendations for Suicide Prevention Programs
SECTION 3 21
A Review of the Research on Suicide among Men in the Middle Years
ñ Scope and Patterns
ñ Risk Factors
ñ Protective Factors
ñ Suggestions from the Research Literature
ñ Conclusion
ñ References
SECTION 4 54
Programs and Resources
Preventing Suicide among Men in the Middle Years
3
ACKNOWLEDGEMENTS
Preventing Suicide among Men in the Middle Years: Recommendations for Suicide Prevention
Programs was developed by the Suicide Prevention Resource Center (SPRC) at Education Develop-
ment Center, Inc. (EDC).
The following people contributed their time and expertise to the development of this resource:
Men in the Middle Years Advisory Group
Michael E. Addis, PhD
Catherine Cerulli, JD, PhD
Kenneth R. Conner, PsyD, MPH
Marnin J. Heisel, PhD, CPsych
Mark S. Kaplan, DrPH
Monica M. Matthieu, PhD, LCSW
Sally Spencer-Thomas, PsyD
Jeffrey C. Sung, MD
External reviewers
Stan Collins, Anara Guard, Ann Haas, Jarrod Hindman, DeQuincy Lezine, Theresa Ly, Scott Ridgway, and
Eduardo Vega
EDC staff
Avery Belyeu, Lisa Capoccia, Jeannette Hudson, Patricia Konarski, Chris Miara, Jason H. Padgett, Marc Posner,
Laurie Rosenblum, Jerry Reed, and Morton Silverman
Marc Posner served as primary writer for this project. Laurie Rosenblum identied the research literature
summarized in A Review of the Research and was the primary author of Programs and Resources. Meredith
Boginski was responsible for the design of the nal publication. Lisa Capoccia directed the project.
© 2016 Education Development Center, Inc. All rights reserved.
Suggested citation
Suicide Prevention Resource Center. (2016). Preventing suicide among men in the middle years: Recommen-
dations for suicide prevention programs. Waltham, MA: Education Development Center, Inc.
Preventing Suicide among Men in the Middle Years
4
ACKNOWLEDGEMENTS
This publication may be reproduced and distributed provided SPRC’s citation and website address
(www.sprc.org) and EDC’s copyright information are retained. For additional information about permission
to use or reprint material from this publication, contact [email protected].
Additional copies of this publication can be downloaded from: http://www.sprc.org/resources-programs/prevent-
ing-suicide-men-middle-years
The people depicted in the photographs in this publication are models and used for illustrative purposes only.
Preventing Suicide among Men in the Middle Years
5
INTRODUCTION
Although men in the middle years (MIMY)—that is, men 35–64 years of age—represent 19
percent of the population of the United States, they account for 40 percent of the suicides in this
country. The number of men in this age group and their relative representation in the U.S. pop-
ulation are both increasing. If the suicide rate among men ages 35–64 is not reduced, both the
number of men in the middle years who die by suicide and their contribution to the overall suicide
rate in the United States will continue to increase.
Unfortunately, the conclusions reached by a 2003 consensus conference on “Preventing Suicide, Attempted
Suicide, and their Antecedents among Men in the Middle Years of Life” still ring true.
[Men in the middle years of life] generally have received the least attention from many of those who are
committed to developing methods of prevention and clinical intervention. Any prevention effort that seeks
to develop a high level of effectiveness must give careful attention to those approaches that “capture” large
segments of the general population, as well as those who carry especially high risk. Men in the middle years,
in particular, will need to be a principal target. (Caine, 2003)
Preventing Suicide among Men in the Middle Years: Recommendations for Suicide Prevention Programs is the
nal report of a project that explored the causes of suicide among men ages 35–64 in the United States as well
as what can be done to alleviate the toll that suicide takes on these men and their families, friends, and commu-
nities. The creation of this publication was informed by the following:
ñ A review of the research on suicide among men 35–64 years of age, focusing on research conducted
in the United States and other Western developed countries. It was often necessary to use data or research
that dened “middle years” somewhat differently than our target group of 35–64 years.
ñ Extensive discussions by an advisory group of experts on suicide among men.
ñ Reviews of drafts by the advisory group, other experts, state suicide prevention coordinators, persons with
lived experience, and others.
ñ Initial queries to participants in the National Action Alliance for Suicide Prevention’s People in the Middle
Years short-term assessment “tiger team” and a survey about existing programs and activities sent to state
suicide prevention planners, selected tribal program planners, and members of the Methamphetamine and
Suicide Prevention Initiative Behavioral Health LISTSERV.
Preventing Suicide among Men in the Middle Years
6
INTRODUCTION
This publication was created to help state and community suicide prevention programs design and implement
projects to prevent suicide among men in the middle years. These could include programs operated by states,
counties, municipalities, tribal entities, coalitions, and nongovernmental organizations (hereafter referred to
as “state and community suicide prevention programs”). In most cases, such programs will work with other
organizations, agencies, and professionals to achieve the goal of reducing suicide among MIMY. We hope that
Preventing Suicide among Men in the Middle Years: Recommendations for Suicide Prevention Programs will
also be of use to these partners, as well as anyone else interested in the health and well-being of men.
Preventing Suicide among Men in the Middle Years: Recommendations for Suicide Prevention Programs is
divided into four sections:
Section 1: Understanding Suicide among Men in the Middle Years: Key Points is a distillation of the con-
clusions drawn from our review of the research and informed by input from the advisory group and other
experts.
Section 2: Recommendations for Suicide Prevention Programs provides guidance for state and community
suicide prevention programs. The recommendations were based on the research review and input from the
advisory group and reviewers.
Section 3: A Review of the Research on Suicide among Men in the Middle Years is based on the current
research and data.
Section 4: Programs and Resources is an annotated list of programs and resources that can be used to
implement activities supporting the Recommendations. Some of these programs and resources were de-
signed for use with MIMY. Others were intended for a broader population but have been used with MIMY.
Few have been evaluated.
SECTION 1
Understanding Suicide among
Men in the Middle Years: Key Points
Preventing Suicide among Men in the Middle Years
8
SECTION 1: Understanding Suicide among Men in the Middle Years: Key Points
These 16 key points represent our conclusions about the scope, patterns, and broader implications of the prob-
lem of suicide among men in the middle years (MIMY). We hope these key points will accomplish the following:
ñ Provide the rationale for the Recommendations for Suicide Prevention Programs
ñ Highlight the role of the partners whose collaboration is essential to implementing the recommendations
ñ Educate and inform staff, collaborators, and the public about suicide among MIMY
1
Much of the increase in suicide in the United States since 1999 can be attributed to an increase in
suicides by men in the 35–64 age group (i.e., men in the middle years).
Men in this age group:
ñ Die by suicide at a substantially higher rate than either women or younger men
ñ Make up more than one half of the male population and approximately one quarter of the total population
of the United States
ñ Will continue to comprise a signicant proportion of the U.S. population for at least the next 25 years
ñ Are not likely to “age out” of risk, as the suicide rate among men ages 65 and older is higher than that of
men ages 35–64
Reducing the overall suicide rate of the United States requires making a substantial reduction in the suicide
rate among men 35–64 years of age.
2
Suicide attempts and ideation have a profound impact on men in the middle years.
Suicide attempts and ideation affect the emotional lives of millions of men and take a toll on their well-being
and their families.
3
The major risk factors for suicide that affect the general population also affect men in the middle years.
These risk factors include mental disorders, alcohol and drug abuse, lack of access to effective behavioral
health services, and access to lethal means.
4
Cultural expectations about masculine identity and behavior can contribute to suicide risk among
men in the middle years.
These expectations can amplify risk factors as well as reduce the effectiveness of interventions that fail to
consider how MIMY think about themselves and their relationships to families, peers, and caregivers. These
cultural expectations include the following characteristics:
ñ Being independent and competent (and thus not seeking help from others)
ñ Concealing emotions (especially emotions that imply vulnerability or helplessness)
ñ Being the family “breadwinner”—an identity that is challenged when a man is unable to provide for his
family (e.g., because he has lost his job)
Preventing Suicide among Men in the Middle Years
9
SECTION 1: Understanding Suicide among Men in the Middle Years: Key Points
5
Men receive less behavioral health treatment than women even though mental and substance abuse
disorders—especially depression—are major risk factors for suicide among men.
Explanations of why men receive less behavioral health treatment than women include (a) a reluctance among
men to recognize or acknowledge that they could benet from behavioral health services as well as to seek
and accept these services, (b) the failure of clinicians to recognize depression in men and refer them to the
appropriate care (which may result from the fact that depression screening tools are largely developed using
female samples), (c) male perception that behavioral health services are not effective, and (d) the actual and
perceived shame and prejudice that can be related to behavioral health diagnoses and treatment.
6
There are questions about whether clinical interventions targeting suicide risk and related mental
health disorders are as effective for men as for women.
Many clinical interventions were developed and evaluated using research subject groups that were solely or
primarily female. Thus, the evaluations could not determine if these interventions are effective for men. Some
sex-specic analyses of evaluation data of programs designed to reduce suicidal behavior have revealed that
their success is entirely based on their effect on women.
7
Alcohol plays a larger role in suicidal behaviors among men than women.
The role of alcohol in suicide includes both (a) a relationship between sustained alcohol abuse (i.e., alcohol
use disorders) and suicide and (b) the immediate effects of alcohol (i.e., intoxication) on critical thinking and
impulsivity.
8
Firearms play a large role in suicide among men in the middle years.
In 2014, 52 percent of suicides among men 35–64 years of age involved rearms (compared to 32 percent
among women in this age group).
9
Men in the middle years who have employment, nancial, and/or legal problems are at higher risk
for suicide than women or younger men facing those issues.
Suicides associated with external circumstances, such as employment, nancial, or legal problems are more
common among MIMY than among women in the middle years. The risk of suicide among adult men—and es-
pecially among MIMY who are closer to retirement—increases during economic downturns. Suicides associat-
ed with external circumstances are less likely to be preceded by a history of suicide attempts and ideation than
are suicides associated with personal circumstances (e.g., mental disorders) or interpersonal circumstances
(e.g., divorce).
q
Intimate partner problems and domestic violence are associated with suicide risk among MIMY.
Men 35–64 years of age appear to be at greater risk of suicide associated with intimate partner problems than
women. Divorce, loss of custody of children, and other relationship issues have the potential to trigger suicides
of men in this age group. MIMY who perpetrate intimate partner violence are also at increased risk of suicide.
Preventing Suicide among Men in the Middle Years
10
SECTION 1: Understanding Suicide among Men in the Middle Years: Key Points
w
Men in lower income groups are at greater risk for suicide than men in higher income groups.
Although the data on the relationship of income and wealth to suicide is limited, research using educational
attainment and occupational skill level suggests that suicide risk is higher among people with limited nancial
resources. MIMY in lower income groups are also disproportionately affected by other risk factors for suicide
(e.g., chronic disease and disability and lack of access to effective health and behavioral health care).
e
Men in the middle years who are involved with the criminal justice system are at higher risk for
suicidal behaviors than other men.
More than 40 percent of men in the 35–64 age group who reported attempting suicide also reported being
arrested and booked for a criminal offense in the past 12 months. The relationship between suicide risk and
involvement with the criminal justice system may be due to the fact that (a) men from lower income groups and
men with mental disorders and/or alcohol or drug use disorders are disproportionately involved with the crimi-
nal justice system and (b) the stress and shame of being involved with the criminal justice system can in and of
itself contribute to suicide risk.
r
Veterans in the middle years (a population that is largely male) have a higher suicide rate than their
peers who have not served in the military.
This phenomenon may be related to (a) trauma associated with combat, (b) interpersonal issues associated
with deployment and re-entry into civilian life, and (c) the demographics of the all-volunteer army.
t
Gay, bisexual, and transgender men in the middle years may be more at risk for suicide than other
men of their age.
The research reveals that lesbian, gay, bisexual, and transgender youth, and young people who do not conform
to standard gender roles, are much more at risk for suicide attempts than other youth. Because most death
data do not include information about sexual orientation and transgender status, we cannot conclusively prove
that these young people are more at risk of suicide than the general population. There is evidence that the still
considerable social disapproval surrounding sexual orientation can contribute to an increased risk of suicidal
behavior and associated mood disorders among adult GBT men.
y
The research on protective factors is not as robust as the research on risk factors and pathology.
There is limited research on interventions that leverage protective factors to prevent suicide among men in the
middle years. Additional research is also needed on interventions that will help boys, male adolescents, and
young men to develop the resilience that will offer protection against suicide risks they may face when they
reach the middle years.
Preventing Suicide among Men in the Middle Years
11
SECTION 1: Understanding Suicide among Men in the Middle Years: Key Points
u
It is important to acknowledge the toll that suicide takes among other groups, including women and
men of other ages, even if the absolute numbers of these deaths are much lower than the number
of suicides among men in the middle years.
This is especially true for groups whose behavioral health disparities (including suicide risk) are rooted in his-
torical and/or contemporary patterns of trauma, discrimination, and exclusion and who are in need of effective
and culturally appropriate suicide prevention efforts (e.g., American Indians and Alaska Natives).
SECTION 2
Recommendations for
Suicide Prevention Programs
Preventing Suicide among Men in the Middle Years
13
SECTION 2: Recommendations for Suicide Prevention Programs
These recommendations outline a framework for the implementation of a comprehensive state or community
effort to prevent suicide among men in the middle years (MIMY). It is virtually impossible to reduce the suicide
rate of the general population without reducing the rate of suicide among MIMY. As a rst step, we suggest that
state and community suicide prevention programs prioritize MIMY as a key target population.
Implementing the Recommendations
Suicide does not have a single cause. Nor does it have a single solution. Effectively preventing suicide requires
a comprehensive set of interventions that address the major factors that put people at risk. Such a comprehen-
sive system can only be created incrementally. The rst step in building this system is creating a strategic plan
informed by the specic scope and patterns of suicide among MIMY in your state or community. This includes
identifying the following:
ñ Populations most at risk
ñ Factors that put these people at risk
ñ Resources that are available for reducing this risk
It is essential that both community and clinical components are included given that both are essential to pre-
venting suicide. This approach is as central to preventing suicide among MIMY as it is to addressing the overall
problem of suicide in a community, a state, or the nation as a whole.
Building a comprehensive suicide prevention program for MIMY includes the following steps:
1. Describe the problem in your state or community, which may differ from that summarized in Understanding
Suicide among Men in the Middle Years: Key Points. These differences can stem from factors such as the
ethnic and income groups represented or the availability of mental health services and lethal means (e.g.,
rearms) among MIMY in your state or community.
2. Identify risk and protective factors. The risk and protective factors for suicide among MIMY are outlined in
the Key Points. An understanding of the specic risk and protective factors in your state or community is
essential to effective prevention.
3. Find appropriate partners. The risk factors affecting MIMY in your state and community, as well as the inter-
ventions that effectively address these risk factors, have implications for the partners you will need.
4. Select, implement, and evaluate interventions. The recommendations can help you select the interventions
that are most appropriate to your needs. A list of tools and other materials that can help you implement the
interventions can be found in the Programs and Resources section of this report. All the resources men-
tioned in the recommendations can be found in that section.
Preventing Suicide among Men in the Middle Years
14
SECTION 2: Recommendations for Suicide Prevention Programs
This report presents 17 recommendations:
ñ Recommendations 1–3 summarize the principles that should inform all activities to prevent suicide among
MIMY.
ñ Recommendations 4–15 describe how state and community suicide prevention programs can help agencies,
organizations, and professionals that work with MIMY to integrate suicide prevention into their activities
ñ Recommendation 16 addresses policies that can reduce suicides associated with rearms, which represent
52 percent of suicides among MIMY, as well as suicides associated with alcohol use.
ñ Recommendation 17 addresses the need for research on suicide and suicide prevention among MIMY.
The Recommendations
To prevent suicide among MIMY, we recommend the following actions for state and community suicide preven-
tion programs:
1
Revise your state or community suicide prevention plan to ensure that it adequately addresses
suicide among MIMY:
ñ Include data and other information about the problem of suicide among MIMY
ñ Identify and revise objectives and activities that could be enhanced to prevent suicide among MIMY
ñ Include new activities specially designed to prevent suicide among MIMY
2
Develop, implement, and facilitate suicide prevention activities based on an understanding of risk
and protective factors among men in the middle years.
Major risk factors for suicide for MIMY include the following:
ñ Depression and other mental disorders
ñ A history of suicidal behavior, including suicidal ideation and attempts
ñ Alcohol use disorder and intoxication
ñ Access to rearms
ñ Illness or disability, including chronic medical conditions, physical
disability, and/or a new diagnosis of a serious illness
ñ Financial stress, both ongoing (e.g., having a low income/low status
occupation) and immediate (e.g., job loss, foreclosure)
ñ Intimate partner problems, both ongoing (e.g., divorce, separation)
and immediate (e.g., breakup, loss of child custody), and committing
or being the victim of intimate partner violence
The term facilitate is used
in several of the recommen-
dations to refer to a range
of activities, including pro-
viding information, resourc-
es, training, and technical
assistance to agencies,
organizations, and profes-
sionals.
Preventing Suicide among Men in the Middle Years
15
SECTION 2: Recommendations for Suicide Prevention Programs
ñ Criminal justice system involvement, both long-term (e.g., men who are awaiting adjudication or on pro-
bation) and immediate (e.g., arrest, impending court date, or impending incarceration)
ñ Other stressors that can precipitate suicide, including family and civil court cases
Major protective factors against suicide for MIMY include the following:
ñ Access to effective health and behavioral health care
ñ Social connectedness to individuals, including friends and family, and to community and social institutions
ñ Coping and problem-solving skills
ñ Reasons for living, meaning in life, and purpose in life
3
Incorporate an understanding of cultural expectations about masculine identity and behavior and
how these expectations affect suicide risk. These expectations impact how MIMY:
ñ Cope with problems and stress.
ñ Seek (or fail to seek) help.
ñ Engage with others and accept help. For example, men can be more accepting of help when it is offered
in the context of reciprocity (i.e., in a mutual exchange in which men accept help from others while also
providing help to others).
ñ Express or “mask” (conceal) depression and suicidal ideation as anger, agitation, nonspecic psychologi-
cal distress, or physical ailments (e.g., back pain).
Masculine identity and behavior can differ based on personal characteristics, upbringing, and critical life expe-
riences, including sexual orientation, race/ethnicity, income level, and military service. This identity and these
expectations and experiences also inuence the venues and channels through which MIMY can be reached
with prevention messages (e.g., sporting events, talk radio, and online media).
4
Collaborate with and facilitate efforts by primary health care providers to:
ñ Incorporate into their practice an understanding of (a) how suicide risk and associated mental disor-
ders (e.g., depression) can be masked in MIMY; (b) the relationship between suicide risk and alcohol
and drug use disorders, chronic disease, and disability; and (c) characteristic patterns of coping and
help-seeking behavior among MIMY
ñ Screen and assess MIMY for suicide risk, and, when indicated, refer patients to behavioral health ser-
vices and follow-up to ensure that the patients are receiving behavioral health care
ñ Intervene to keep patients safe using brief interventions (e.g., safety planning that includes teaching men
how to leverage their peer and social support networks and counseling on reducing access to lethal
means, especially rearms) and involving the patient’s family
ñ Enhance coping, problem-solving, and self-management skills among MIMY at risk for suicide using
interventions such as motivational interviewing and problem-solving therapy
Preventing Suicide among Men in the Middle Years
16
SECTION 2: Recommendations for Suicide Prevention Programs
ñ Provide SBIRT (Screening, Brief Intervention, and Referral to Treatment) to MIMY with alcohol or drug
use disorders
5
Collaborate with and facilitate efforts by emergency departments to:
ñ Incorporate into their practice an understanding of (a) how suicide risk and associated mental disor-
ders (e.g., depression) can be masked in MIMY; (b) the relationship between suicide risk and alcohol
and drug use disorders, chronic disease, and disability; and (c) characteristic patterns of coping and
help-seeking behavior among MIMY
ñ Screen and assess MIMY for suicide risk if there is any indication
that such risk is present
ñ Screen and assess all intoxicated MIMY presenting in emergency
departments for suicide risk
ñ Provide SBIRT (Screening, Brief Intervention, and Referral to Treat-
ment) to MIMY with alcohol or drug use disorders
ñ Implement protocols for responding to suicide risk in patients, includ-
ing using brief interventions (e.g., safety planning that includes teach-
ing men how to leverage their peer and social support networks and
counseling on reducing access to lethal means, especially rearms);
involving the patient’s family or friends; linking the patient to outpa-
tient behavioral health treatment; and hospitalization
ñ Facilitate care transitions, including rapid referral to behavioral health
services
ñ Provide follow-up to discharged patients with brief communications
(e.g., postcards, e-mails, or texts) to facilitate adherence to discharge
plan and demonstrate a continued interest in patient well-being (i.e.,
social connectedness)
ñ Implement the guidance included in Caring for Adult Patients with Suicide Risk: A Consensus Guide for
Emergency Departments
6
Collaborate with and facilitate efforts by behavioral health services to:
ñ Incorporate into their practice an understanding of (a) how suicide risk and associated mental disor-
ders (e.g., depression) can be masked in MIMY; (b) the relationship between suicide risk and alcohol
and drug use disorders, chronic disease, and disability; and (c) characteristic patterns of coping and
help-seeking behavior among MIMY
ñ Screen MIMY for suicide risk during entry to care and during the course of care if there are indications of
potential risk; provide more in-depth assessment for men who screen positive or when risk is suspected
The Zero Suicide Toolkit
includes resources that can
help you implement many
of the recommendations for
primary care and behavioral
health care systems and
emergency departments.
The toolkit includes sec-
tions on training options,
suicide screening and risk
formulation, evidence-based
treatments (including thera-
pies), and care transitions.
Preventing Suicide among Men in the Middle Years
17
SECTION 2: Recommendations for Suicide Prevention Programs
ñ Use strategies to keep men safe, including brief interventions (e.g., safety planning that includes teaching
men how to leverage their peer and social support networks and counseling on reducing access to lethal
means, especially rearms) involving the patient’s family, medication, or hospitalization
ñ Use psychotherapies that directly address suicide risk and enhance coping, problem-solving, and
self-management skills
ñ Positively engage patients in their own care
ñ Explore alternative settings and methods for bringing behavioral health services to men (e.g., workplaces,
telepsychiatry)
7
Collaborate with crisis centers to educate staff about:
ñ How suicide risk and associated mental disorders (e.g., depression) present or can be masked among
MIMY
ñ Screening and assessing MIMY who have been diagnosed with depression, other mental disorders, or
an alcohol or drug use disorder for suicide risk
ñ Keeping MIMY at risk safe by using strategies including brief interventions (e.g., safety planning that in-
cludes teaching men how to leverage their peer and social support networks and counseling on reducing
access to lethal means, especially rearms) and involving the patient’s family
8
Collaborate with and facilitate efforts by agencies and organizations that work to prevent and treat
alcohol abuse to:
ñ Incorporate into their practice an understanding of (a) the relationship between alcohol use disorder,
intoxication, and suicide risk, (b) how suicide risk and associated mental disorders (e.g., depression) can
be masked in MIMY, and (c) characteristic patterns of coping and help-seeking behavior among MIMY
ñ Train staff to recognize, assess, and manage suicide risk and associated mental disorders (e.g., depres-
sion) among their clients
ñ Incorporate suicide prevention-specic treatment and practices into their programs based on the recom-
mendations of SAMHSAs Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment:
A Treatment Improvement Protocol (TIP 50)
ñ Facilitate transitions to mental health care when appropriate
ñ Include information on the relationship of alcohol and suicide among MIMY in resources designed to
inform state and local policies to reduce alcohol use disorders and other forms of alcohol misuse (e.g.,
binge drinking). Such information can be found under A Review of the Research on Suicide among Men
in the Middle Years (below).
Preventing Suicide among Men in the Middle Years
18
SECTION 2: Recommendations for Suicide Prevention Programs
9
Collaborate with organizations and businesses that serve or represent rearm owners and users
(including rearm retailers, rearm safety instructors, ring ranges, and gun and hunting clubs) to
create a culture of safety by:
ñ Providing them with information on the role of rearms in suicide and how suicide can be prevented
ñ Providing gatekeeper training to rearm owners, staff of rearm-related businesses, and members of gun
and hunting clubs and other rearms-related organizations
ñ Training rearm retailers to identify and avoid or postpone sales to customers who may be at risk for
suicide
ñ Incorporating material on lethal means reduction into rearm safety training
q
Facilitate efforts by criminal justice, law enforcement, and correctional agencies to:
ñ Establish procedures and provide training that will help criminal justice, law enforcement, and corrections
ofcers safely and effectively respond to people at risk for suicide. This training should include informa-
tion about the association between suicide risk and (1) involvement in the criminal justice system and (2)
mental health and substance abuse disorders.
ñ Utilize the Sequential Intercept Model (SIM) to prevent people with mental disorders and alcohol and
drug use disorders from entering or moving deeper into the criminal justice system by diverting them
to community-based services when appropriate, providing behavioral health services in correctional
facilities, and providing effective reentry transitional programs for people being discharged from
correctional facilities
ñ Screen MIMY for suicide risk during intake in jails and prisons and implement best practices for address-
ing this risk (e.g., monitoring inmates and eliminating items and physical features from cells that could be
used for self-harm, such as those that could be used for hanging)
ñ Provide behavioral health services to MIMY in jails and prisons, including treatment for depression and
other mental disorders and alcohol and drug use disorders
w
Help agencies, programs, and professionals that work with men having nancial, legal, or relation-
ship problems (including civil court issues) to identify and refer those who may be at risk of suicide.
These include agencies and programs serving MIMY who have:
ñ Financial problems – These agencies, programs, and professionals would include but not be limited to
affordable housing agencies, job training programs, unemployment services, employee assistance pro-
grams, human resource ofces, public defenders, nancial advisors, and bankruptcy attorneys.
ñ Intimate partner problems – These agencies, programs, and professionals would include divorce attor-
neys, family law attorneys, marriage counselors, and programs that counsel men involved in domestic
violence.
ñ Legal problems – These agencies, programs, and professionals might include family, civil, and bankruptcy
courts; attorneys; mediation services; and legal aid law clinics.
Preventing Suicide among Men in the Middle Years
19
SECTION 2: Recommendations for Suicide Prevention Programs
e
Help workplaces that employ substantial numbers of men in the middle years implement programs to:
ñ Teach employees how to identify and respond to coworkers who may be at risk for suicide or experienc-
ing a mental health crisis
ñ Establish postvention procedures for responding to a suicide by a worker (whether or not the death
occurs in the workplace)
ñ Provide specialized suicide prevention training for human resources staff and/or employee assistance
providers for employees who are being terminated or laid off
ñ Implement suicide prevention activities such as those described in the National Action Alliance for
Suicide Prevention’s Comprehensive Blueprint for Workplace Suicide Prevention
ñ Foster a supportive workplace environment free from attitudes and discrimination that might deter people
from seeking help for stress and mental health issues
r
Work with television and radio stations, newspapers and magazines, and online news sites to
develop and implement outreach and social norms campaigns to:
ñ Teach men how to recognize and seek help for suicide risk and associated mental disorders (e.g.,
depression) and alcohol and drug disorders for themselves and their peers
ñ Teach family and friends to identify MIMY at risk of suicide and how to encourage them to seek care
ñ Promote help seeking as a social norm for men
ñ Emphasize reaching men who are socially isolated and/or may not interact with health care providers
t
Help organizations and agencies that address suicide risk among men in the middle years
implement activities that strengthen protective factors.
These organizations and agencies (described in Recommendations 4–12 above) could, for example, create
projects that teach coping skills to MIMY who are unemployed, separated, divorced, widowed, in recovery,
disabled, or chronically ill.
y
Support the creation of community-based groups that create social connectedness and enhance
self-worth, meaning in life, and a sense of purpose among men in the middle years.
For example, identify natural helpers or community leaders who could help organize programs that target and
promote protective factors among MIMY with common backgrounds (e.g., veterans or American Indians) or
risk factors (e.g., unemployment, alcohol or drug abuse).
u
Promote awareness of policies that have been shown to be associated with a reduction in suicide,
including the following:
ñ Requiring permits to purchase handguns, handgun registration, and licenses to own handguns
ñ Requiring background checks and waiting periods prior to completing a handgun purchase
Preventing Suicide among Men in the Middle Years
20
SECTION 2: Recommendations for Suicide Prevention Programs
ñ Requiring privately owned handguns to be safely stored
ñ Restricting the open carrying of handguns
ñ Restricting the number of liquor licenses available in geographic areas such as neighborhoods, munici-
palities, or counties to limit the density of bars and retail liquor outlets
i
Researchers should improve the understanding of risk and protective factors and help develop
effective interventions for suicide among men in the middle years by:
ñ Reporting data by sex and age group and, if possible, race/ethnicity, socioeconomic status, and sexual
orientation
ñ Working with state and community suicide prevention programs to evaluate their efforts
ñ Clarifying the following issues:
1.
What factors contribute to suicide risk among MIMY? How can these factors be reduced?
2. What factors protect MIMY against suicide risk, and how can this protection be strengthened? What
programs can effectively increase these protective factors among MIMY?
3.
How can suicide prevention programs more effectively prevent suicide among MIMY by responding to
their cultural and behavioral expectations, their learning styles, and the ways in which they characteris-
tically seek and accept help?
4.
How can screening, assessment, and treatment of suicide risk and associated mental disorders be
made more effective for MIMY?
5.
How can help seeking and treatment engagement be enhanced for MIMY, and what roles can family,
peers, and the media play in these efforts?
6.
What are the differences in the patterns of suicide and suicide attempts among MIMY based on
(1) age—specically between younger (35–49 years of age) and older (50–64 years of age) MIMY,
(2) income level, and (3) sexual orientation and gender identity? What are the implications of these
differences for designing effective interventions for men in these age groups?
7.
What specic risk and protective factors are at work among groups of MIMY that may be at particular-
ly high risk (e.g., veterans, GBT men)?
8.
Does the current rate of suicide among MIMY represent a temporary cohort effect or a long-term pat-
tern? What implications does this have for planning and implementing suicide prevention programs in
the future?
9.
What can be done earlier in men’s lives (including childhood and adolescence) that will promote resil-
ience and protection against suicide when they enter the middle years?
SECTION 3
A Review of the Research on Suicide
among Men in the Middle Years
Preventing Suicide among Men in the Middle Years
22
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
This review is based on the published research and surveillance data as well as on an analysis of data from
SAMHSA’s National Survey of Drug Use and Health (NSDUH). The review focused on research on men 35–64
years of age conducted in the United States and other Western developed countries. It was often necessary to
use data or research that dened middle years somewhat differently than our target group of 35–64 years. We
did not review (1) interventions targeting boys, adolescents, or younger men that might reduce risk or protect
against the onset of suicidal behaviors as these men age or (2) interventions targeting men older than 64. How-
ever, we acknowledge the role of such interventions in comprehensive efforts to prevent suicide.
Scope and Patterns
Men in the middle years (MIMY) disproportionately die by suicide. In 2014, men 35–64 years of age represent-
ed 19 percent of the population of the United States (U.S. Census Bureau, 2014), but they accounted for 40
percent of suicides (CDC, 2014).
About half of the American population is male. As of 2014, 39.4 percent of the total U.S. population was 35 to
64 years of age (U.S. Census Bureau, 2014). The number of people in the middle years, as well as the propor-
tion of the U.S. population that is in this age group, is increasing.
ñ The number of people ages 45–64 years in the United States in the years 2000–2010 increased by 31.5
percent (U.S. Census Bureau, 2011).
ñ The median age of the U.S. population increased from 29.5 years in 1960 to 37.2 years in 2010 (U.S. Cen-
sus Bureau, 2011).
Suicidal Behavior among Men in the Middle Years
The suicide rate and the absolute number of suicides in the United States have continually increased since
1999. The number of suicides in the United States rose from 29,350 in 1999 to 42,773 in 2014 (Figure 1).
Figure 1. Suicide Deaths in the U.S. by Year
Number of Suicide Deaths in the U.S. by Year, 1999–2014
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Number of Suicide
Deaths
Source: Data from Centers for Disease Control and Prevention (2014).
Preventing Suicide among Men in the Middle Years
23
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
The suicide rate in the United States increased from 10.48/100,000 in 1999 to 13.41/100,000 in 2014 (Figure 2).
Figure 2. Suicide Rate in the U.S. by Year
Suicide Rate per 100,000 in the U.S. by Year, 1999–2014
14
12
10
8
6
4
2
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Crude Rate
Source: Data from Centers for Disease Control and Prevention (2014).
Much of the growth in the suicide rate and the number of suicides in the United States since 1999 can be
attributed to an increase in suicides by men 35–64 years of age (Figure 3).
Figure 3. Crude Suicide Rates in the U.S. by Age and Sex
35
30
25
20
15
10
5
0
Rate per 100,000
Men Ages 18-34
Women Ages 18-34
Women Ages 35-64
Women Ages 65+
Men Ages 35-64
Men Ages 65+
1999
20.39
21.5
32.17
4.07
6.18
4.34
2000
19.83
21.92
31.07
3.82
6.27
4.03
2001
20.49
22.76
31.42
3.85
6.54
3.89
2002
20.35
23.66
31.8
4.01
6.78
4.11
2003
20.31
23.45
29.74
4.07
6.81
3.81
2004
20.66
23.48
28.95
4.33
7. 4
3.81
2005
20.1
23.71
29.45
4.31
7.02
4.03
2006
20.11
24.24
28.36
4.18
7. 4 6
3.91
2007
20.57
25.14
28.4
4.43
7.82
3.92
2008
20.38
26.32
29.21
4.52
7. 87
4.1
2009
20.22
26.87
29.05
4.56
8.09
4.04
2010
21.65
27.6 4
29
4.92
8.21
4.19
2011
22.18
27.55
29.41
5.25
8.4
4.46
2012
22.16
28.22
29.5
5.36
8.69
4.5
2013
22.08
27.6 4
30.93
5.57
8.81
4.59
2014
22.70
28.13
31.39
5.65
9.29
5.04
Crude Suicide Rates per 100,000 in the U.S.
by Age and Sex, 1999-2014
Source: Data from Centers for Disease Control and Prevention (2014).
Preventing Suicide among Men in the Middle Years
24
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
The largest increase in the suicide rate during the years 1999–2014 was among people 35–64 years of age.
Although the increase in the suicide rate for women 35–64 was somewhat higher than that for men in that age
group, the suicide rate for MIMY continues to be substantially higher than that for women in the middle years
(Figure 3). Men ages 35–64 represent a disproportional percentage of suicides in this country (Figure 4).
Figure 4. Suicide in the United States, 2014
Suicide in the United States, 2014
Men 35-64 Men 0-34 & 65+ Women 0-65+
Source: Data from Centers for Disease Control and Prevention (2014).
The suicide rate of men rises with age, and suicide rates among men are higher than those among women in
every age group (Figure 5).
Figure 5. Suicide Rates in the U.S. by Age and Sex, 2014
Suicide Rates in the U.S by Age and Sex, 2014
Men Women
18-34
22.70
5.65
35-64
25.13
9.29
65+
31.39
5.04
Source: Data from Centers for Disease Control and Prevention (2014).
40.06%
59.94%
Preventing Suicide among Men in the Middle Years
25
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
According to the NSDUH, an average of 0.4 percent of men 35–64 years of age made a suicide attempt during the
years 2008–2013. This was the same as the percentage of women 35–64 who made an attempt, but lower than
the percentage of men 18–34 years of age (Table 1). Using U.S. Census data, we can estimate that in 2013:
ñ 242,779 men 35–64 years of age attempted suicide
ñ 2,306,402 men 35–64 years of age had serious thoughts of suicide
Table 1. Average Percentages of Attempts and Serious Thoughts of Suicide
in the Past 12 Months by Sex and Age Group, 2008–2013
Sex/Age Attempts Serious Thoughts of Suicide
Men 18-34 0.7% 4.9%
Men 35-64 0.4% 3.4%
Women 35-64 0.4% 3.7%
Source: Data from the National Survey on Drug Use and Health, 2008-2013, Substance Abuse Mental Health Services
Administration (2013).
The prevalence of suicide attempts is higher than the rate of individuals who make attempts because some indi-
viduals attempt suicide more than once over the course of a year.
Although men and women in the middle years attempt suicide at about the same rate (400/100,000 as indicated
in the previous table), there is a difference in the relationship of attempts to suicides based on sex. Hempstead
and Phillips (2015) found that 36.7 percent of women in the 40–64 age group who died by suicide had made at
least one attempt prior to the attempt that resulted in their death. Only 18.9 percent of the men in that age group
who died by suicide had made a prior attempt. Hempstead and Phillips suggest that this may be at least partially
explained by the following facts:
ñ Suicides associated with external circumstances (e.g., job or legal problems) are less likely to be preceded
by a nonfatal suicide attempt than are suicides associated with internal circumstances (e.g., mental health
conditions) or interpersonal problems (e.g., divorce).
ñ Suicides by men in this age group are signicantly more likely to be associated with external circumstances
than suicides by men in other age groups or women.
The relationship between suicide attempts and suicide among MIMY may also be at least partially attributed to
the fact that men in this age group tend to use more lethal means to harm themselves (primarily guns), and thus
they are less likely to survive their initial suicide attempt than are women. The percentages of men and women
in the middle years who received medical attention after a suicide attempt were similar (67 percent men; 72.7
percent women). Both of these percentages were substantially higher than that of people in the 18–34 age
group (47 percent men; 46.3 percent women). Non-fatal attempts by men in the 35–64 age group result in
more severe injuries than those by younger men (SAMHSA, 2013).
An analysis of pooled data from the NSDUH and the National Vital Statistics System (Han et al., 2016) found that
7.6 percent of men 45 years and older who attempt suicide in the United States during a 12-month period actually
die by suicide. This includes both men who die on their rst attempt and men who died on a subsequent attempt
Preventing Suicide among Men in the Middle Years
26
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
in this 12-month period. This rate was signicantly higher than the corresponding rates for women 45 years and
older (2.6 percent), men ages 26–44 (5.1 percent), and men ages 18–25 years (1.9 percent). This study also
revealed that suicide rates among people who attempt suicide tend to increase with age and decrease with
educational attainment.
Race/Ethnicity
Men in the 35–64 age group have substantially higher suicide rates than women in that age group across the
racial/ethnic spectrum. The suicide rate among white men 35–64 years of age is higher than that of younger
white men 18–34, which is not the case in other racial/ethnic groups (Figure 6).
Figure 6. Suicide Rates by Racial/Ethnic Group, 2014
Suicide Rates per 100,000 by Racial/Ethnic Group, 2014
Women Ages 35-64 Men ages 18-34Men ages 35-64
Asian/Pacific Islander
Hispanic
Black
American Indian/Alaskan Native
White
12.30
35.91
25.55
8.52
30.54
47.58
2.83
11.20
15.70
3.20
12.32
13.25
3.63
9.14
12.94
Source: Data from Centers for Disease Control and Prevention (2014).
White men account for the majority of suicide attempts by men in the United States. However, suicide attempts
by black and Hispanic men 35–64 years of age are disproportionately higher than their representation among
males in these ethnic groups (Table 2).
Table 2. Percentage of Men Who Attempted Suicide in the Past 12 Months by Racial/Ethnic
Group and Percentage of the Male Population Ages 35–64 by Racial Ethnic Group, 2008-2013
Racial/Ethnic Group Men 18–34 Men 35–64 Percentage of Male Population,
Ages 35–64 Years
White (non-Hispanic) 58.3% 55.7% 69%
Black (non-Hispanic) 15.3% 19.9% 11%
Hispanic 19.2% 17.9% 12%
Sources: Attempt data from National Survey of Drug Use and Health, 2008–2013, Substance Abuse and Mental Health Services Administration (2013);
percentage of male population data from Centers for Disease Control and Prevention (2014).
Preventing Suicide among Men in the Middle Years
27
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
An accurate picture of suicide attempts among American Indians/Alaska Natives and Asians and Pacic Island-
ers could not be calculated using NSDUH data because of the small number of members of these groups who
participated in the survey.
Men in the Criminal Justice System
The data reveal that 40.6 percent of men in the 35–64 age group who had attempted suicide in the past 12
months (and 44.2 percent of those who had serious thoughts of suicide) had been arrested and booked for a
criminal offense during that period (Figure 7).
Figure 7. Arrests and Bookings among People Ages 35–64 Reporting Suicidal Behaviors, by Sex
Arrests & Bookings (Past 12 Months) among
People 35-64 Years of Age Reporting Suicidal
Behaviors (Past 12 Months) by Sex (2008-2013)
Men
Attempts
Women
Attempts
Men Serious
Thoughts
Women Serious
Thoughts
40.60%
44.20%
29.00%
23.20%
Source: Data from the National Survey on Drug Use and Health, 2008-2013, Substance Abuse Mental Health Services Administration (2013).
Hempstead and Phillips (2015) also found that a signicantly higher percentage of suicides among men 40–64
years of age were associated with criminal problems than were suicides of women (11.5 percent versus 3.8 percent).
The bulk of arrests in the United States are related to crimes that involve drugs and alcohol (U.S. Dept. of Jus-
tice, Federal Bureau of Investigation, 2012), which are behaviors associated with suicide risk. The arrest rate
for men and the male arrest rate for crimes related to drugs and alcohol are about three to four times those of
women (Snyder, 2012).
Schiff et al. (2015) analyzed National Violent Death Reporting System (NVDRS) data for men ages 35–64 who
died by suicide and had experienced a recent crisis (such as a divorce or arrest). The study excluded men with
a known history of mental health or substance abuse problems so that the factors putting men at risk for suicide
independent of these behavioral health issues could be identied. About half of the men in the sample had ex-
perienced criminal and/or legal problems. About 20 percent of the suicides of men with criminal/legal problems
showed signs of premeditation. Men who did not have criminal/legal problems were signicantly more likely to
show signs of premeditation than men with criminal legal problems.
Preventing Suicide among Men in the Middle Years
28
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Suicide is the leading cause of death in jails. The average annual suicide rate (2000 –2013) among jail inmates
(male and female) was 41/100,000. Men die by suicide in jails at a rate 1.5 times that of women. About half of
suicides in jails are among inmates over the age of 35. The suicide rates of adults in jails and prisons generally
increase with age (Figure 8). (Noonan, Rohloff, & Ginder, 2015)
Figure 8. Average Annual Suicide Rates, Inmates by Age
Average Annual Suicide Rates
per 100,000 Inmates by age, 2000-2013
55 or older
45-55
35-44
25-34
18-24
<17
Jails
Prisons
100 80 60 40 4020 200
Source: Data from Bureau of Justice Statistics, as cited in Noonan, Rohloff, and Ginder (2015).
.
Suicide attempts by both men and women (including those that occurred prior to incarceration) were reported
by 13 percent of inmates in state prisons, 6 percent of those in federal prisons, and 12.9 percent of those in
local jails (James & Glaze, 2006).
The latest U.S. Department of Justice data on mental health problems among inmates (James & Glaze, 2006)
reveal that as of 2005, “more than half of all prison and jail inmates had a mental health problem.” This includes:
ñ 56 percent of inmates in state prisons
ñ 45 percent of inmates in federal prisons
ñ 43 percent of inmates in jails
Seventy-four percent of state prisoners and 76 percent of female inmates in state prisons “who had a mental
health problem met criteria for substance dependence or abuse” (James & Glaze, 2006). Among state prison-
ers, 43 percent with mental health problems reported binge drinking. In contrast, 29 percent of state prisoners
without mental health problems reported binge drinking.
Preventing Suicide among Men in the Middle Years
29
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Gay, Bisexual, and Transgender (GBT) Men
Relatively little information is available about suicide rates among people who are lesbian, gay, bisexual, and
transgender (LGBT) because vital statistics data do not include information on sexual orientation or gender
identity. Gay and bisexual men have signicantly higher suicide attempt rates than their heterosexual peers
(Haas et al., 2011). However most of the research has been done on younger men. Some research indicates
that, at least among adolescents, gender nonconformity rather than sexual orientation per se is associated with
this elevated risk.
Several recent studies suggest that LGB people are also at increased risk for suicide (Hatzenbuehler et al., 2014;
Ploderl et al., 2013). There is evidence that older GBT men experience higher levels of depression and psycholog-
ical stress than heterosexual people (Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders &
LGBT Movement Advancement project, 2010). An analysis that correlated mortality information from the National
Death Index with measures of prejudice from the General Social Survey found that LGB people living in commu-
nities characterized by a high level of prejudice against sexual minorities had an average life expectancy 12 years
shorter than their peers who lived in communities with a low level of prejudice. The average age at which LGB
people died by suicide in high-prejudice communities was 37.5 years compared to 55.7 years in low-prejudice
communities (Hatzenbuehler et al., 2014). The data were not broken out by sex or gender.
Data from the National Transgender Discrimination survey revealed elevated suicide attempt rates among trans-
gender people. Although these rates decline with age, the rate for transgender men in the middle years is higher
than that of the general population and of gay and bisexual men (Haas, Rodgers, & Herman, 2014).
Veterans
Historically, veterans have had lower suicide rates than their non-veteran peers (Kang & Bullman, 2009). How-
ever, this pattern is changing. An analysis of 2003–2008 NVDRS data (Kaplan, McFarland, Huguet, & Valen-
stein, 2012) found that male veterans had signicantly higher suicide rates than males who were not veterans
(although this pattern did not hold for men 65 years of age and older). An analysis of data from the U.S. Depart-
ment of Veterans Affairs (Hoffmire, Kemp, & Bossarte, 2015) found that “from 2000 to 2010, both the crude and
age-adjusted veteran suicide rates for men and women combined increased by approximately 25 percent while
the comparable nonveteran rates increased by approximately 12 percent.” The suicide rate for male veterans
was 20 percent higher than for men who were not veterans.
Hoffmire, Kemp, & Bossarte (2015) suggest that the rate of suicide among veterans may be related to (a) trau-
ma associated with combat, (b) interpersonal issues associated with deployment and re-entry into civilian life,
and (c) the demographics of the all-volunteer army.
Men 30–64 years of age have the highest suicide rate among patients who seek health care services from the
Veterans Health Administration (Blow et al., 2012). A majority of veterans who die by suicide are age 50 or
older (Kemp & Bossarte, 2012).
In a study of veterans who died by suicide, veterans ages 35–64 “were more likely to be White, married, and
to have died in a rural area than their younger counterparts” (Kaplan et al., 2012). This study also found that
younger veterans were more likely to have intimate partner problems while older veterans were more likely to
have health problems. Veterans 35–44 were more likely to have received a mental health diagnosis than those
under the age of 35 or older than 44. Firearms were more likely to have played a role in suicides by older
Preventing Suicide among Men in the Middle Years
30
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
veterans. Younger veterans who died by suicide were more likely to have a history of prior suicide attempts than
older veterans.
Murder-Suicide
Although incidents in which a person kills others, and then dies by suicide, are rare, they receive a great deal
of media attention. Little information on murder-suicides is available. A review of the literature (Eliason, 2009)
revealed the following:
ñ The murder-suicide rate in the United States is approximately 0.2–0.3/100,000 a year and is relatively stable.
ñ Most murder-suicides involve “a man killing his wife, girlfriend, ex-wife, or ex-girlfriend.” Some involve a
parent killing his or her children.
ñ The mean age of the perpetrators of murder-suicide is 40–50 years. This is older than the mean age of
people who perpetrate homicide.
Cohen, Llorente, and Eisdorfer (1998) found that while younger men tend to kill their wives and themselves
after marital discord, older couples who die in murder-suicides often have medical problems.
Schiff et al. (2015) found that 41 percent of men between the ages of 35 and 64 who died by suicide and had
criminal and/or legal problems (but did not have a history of mental health or substance abuse problems) had
committed or attempted homicide prior to their death. The majority of the victims of these homicides and at-
tempted homicides were intimate partners, former intimate partners, or family members.
Eliason (2009) concluded:
There are certain clinical presentations that should alert mental health professionals to be suspicious of the
risk of possible murder-suicide: a middle-aged man who is recently separated or facing pending estrange-
ment from his intimate partner and who is depressed and has access to rearms; or an older male who is
the primary caregiver for a spouse who is ill or debilitated, where there is a recent onset of new illness in the
male, depression, and access to rearms.
Risk Factors for Suicide among Men in the Middle Years
Risk factors associated with suicide can be divided into these three categories: individual or personal risk
factors (e.g., mental disorders), relationship or interpersonal risk factors (e.g., intimate partner problems), and
environmental or external risk factors (e.g., lack of access to behavioral health care).
Many of the major risk factors associated with suicidal behaviors among MIMY (Figure 9) are also major risk
factors for women and for men in other age groups (U.S. Department of Health and Human Services, Ofce of
the Surgeon General, & National Action Alliance for Suicide Prevention, 2012). These include:
ñ Prior suicide attempts
ñ Mental disorders
ñ Substance abuse
ñ Chronic disease and disability
ñ Social isolation
ñ Access to lethal means
ñ Lack of access to behavioral health care
Preventing Suicide among Men in the Middle Years
31
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Figure 9. Risk Factors for Suicidal Behaviors among MIMY
Major Risk Factors Associated with Suicidal Behaviors among
MIMY
SUICIDE
Of men ages 40–65 who died by suicide in the United States (2005–2010):
43.1 percent experienced depressed mood (Hempstead & Phillips, 2015)
36.8 percent had alcohol dependence or another substance problem (Hempstead & Phillips, 2015)
69.6 percent were currently not being treated for a mental health problem (Hempstead & Phillips, 2015)
3 7. 1 percent had intimate partner problems, for example, divorce, argument, or violence (Hempstead &
Phillips, 2015)
36.2 percent had job or nancial problems (Hempstead & Phillips, 2015)
54 percent used rearms (Centers for Disease Control and Prevention, 2014)
SUICIDE ATTEMPTS
Of men ages 35–64 who attempted suicide in the past year in the United States (2008–2013):
40.6 percent had experienced a major depressive episode
41.7 percent had been binge drinking
32.4 percent had a substance abuse disorder
42.2 percent did not receive mental health treatment
30.4 percent were disabled and could not work
39.3 percent had an income of less than 100 percent of the Federal Poverty Line
40.6 percent had a criminal history (arrested and booked)
Source: Data from the National Survey on Drug Use and Health, Substance Abuse Mental Health Services Administration (2013).
Preventing Suicide among Men in the Middle Years
32
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Mental Disorders
Draper, Kolves, De Leo, & Snowdon (2013) found that 75.1 percent of people who died by suicide had a
psychiatric disorder—although this percentage decreases with age. A meta-analysis of psychological autopsy
studies of people (all ages and both sexes) who died by suicide found that “87.3 percent . . . had been diagnosed
with a mental disorder prior to their death” (Arsenault-Lapierre, Kim, & Turkecki, 2004). Arsenault-Lapierre et al.
(2004) also reported that men who died by suicide tended to be diagnosed with substance abuse, personality
disorders, and/or childhood disorders.
An analysis of NVDRS data revealed that 43.1 percent of men 40–64 years of age who died by suicide had
experienced depressed mood. This percentage was not signicantly different from that of women who died by
suicide (Hempstead & Phillips, 2015).
NSDUH data (SAMHSA, 2013) revealed that 40.6 percent of men in the 35–64 age group who attempted
suicide in the past 12 months and 45.2 percent of those who had serious suicidal thoughts also experienced a
major depressive episode during that period. The percentages for women were 62.9 percent and 55.1 percent,
respectively. The percentage of younger adults of both sexes who had attempted or seriously thought about
suicide and suffered a major depressive episode was also extremely high.
There is evidence that clinicians systematically fail to identify depression in men because of “the widespread
use of generic diagnostic criteria that are not sensitive to depression in men” (Oliffe & Phillips, 2008). Hemp-
stead and Phillips (2015) found that 69.6 percent of men who died by suicide were not currently in treatment
for any mental health issues.
Alcohol and Drugs
NVDRS data reveal that 36.8 percent of men (age 40–64) who died by suicide were dependent on alcohol or
had another substance abuse problem. Men who died by suicide were signicantly more likely to be dependent
on alcohol than women who died by suicide (although no difference was found in other substance problems)
(Hempstead & Phillips, 2015). Acute alcohol intoxication at the time of death is more common among men than
women, men with low education status, men and women in the 35–44 age group, and American Indians and
Alaska Natives (Kaplan et al., 2013).
Research has revealed a signicant association between the density of bars and retail liquor stores in an area
and the suicide rate in that area. The authors of some of these studies have suggested that policies that reduce
the density of liquor stores in a geographic area (e.g., restricting the number of liquor licenses in a neighbor-
hood, town, or county) may reduce the rate of suicide in that area (Khaleel et al., 2016; Giesbrecht et al., 2015;
Johnson, Gruenwald, & Remer, 2009; Escobedo & Ortiz, 2002).
NSDUH data show that the patterns of alcohol and drug abuse among MIMY who have attempted or thought
seriously about suicide are more similar to those of younger men than to women in the middle years. Substantial
percentages of MIMY who reported suicide attempts also reported binge or heavy alcohol use or substance or
alcohol use disorders (Table 3).
Preventing Suicide among Men in the Middle Years
33
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Table 3. Percentage of Alcohol and Drug Abuse Indicators (Past 12 Months) among Those
Reporting Suicidal Behaviors (Past 12 Months), by Sex and Age, 2008–2013
Men Attempts
(18–34 years)
Men Attempts
(35–64 years)
Women
Attempts
(35–64 years)
Men Serious
Thoughts
(18–34 years)
Men Serious
Thoughts
(35–64 years)
Women Serious
Thoughts
(35–64 years)
Binge Alcohol
Use
50.7% 41.7% 28.7% 50.6% 34.6% 19.5%
Heavy Alcohol
Use
22.6% 18.7% 5.4% 21.7% 13.8% 5.3%
Substance
Use Disorder
51.3% 32.4% 24.7% 44.3% 24.6% 16.3%
Alcohol Use
Disorder
42.9% 26.3% 19.2% 34.2% 20.5% 12.3%
Illicit Drug
Disorder/
Prescription
Drug Use
Disorder
30.8% 16.5% 8.9% 23.2% 9.9% 6.2%
Alcohol and/
or Drug Use
Treatment
17.2% 21.2% 12.9% 9.5% 9.4% 6.5%
Source: Data from the National Survey on Drug Use and Health, 2008-2013, Substance Abuse Mental Health Services Administration (2013).
An analysis of NVDRS data revealed that, in every age group, blood alcohol content was higher in men than in
women who died in suicides associated with rearms, hanging, or poisoning (Conner et al., 2014). This indi-
cates that intoxication is a risk factor for suicide among people whose alcohol use does not rise to the level of a
diagnosable disorder. The association between intoxication and suicide is usually attributed to alcohol’s effects
on inhibition, judgment, and impulsivity. It has also been suggested that depressed men may self-medicate with
alcohol or drugs rather than seek mental health care. Alcohol and drug use can thus conceal depression as well
as amplify the suicide risk in men suffering from depression (Brownhill & Wilhelm, 2002).
Means of Suicide
In 2014, 52 percent of suicides among men 35–64 years of age involved rearms (compared to 32 percent
among women in this age group) (CDC, 2014). Firearms are more likely to result in a death than other meth-
ods of suicide. The fact that MIMY tend to choose rearms as a means of self-harm has a major impact on the
suicide rate of this age group.
The rate of rearms-related suicide among men in the 35–64 age group is higher than among men ages 18–34
and much higher than among women ages 35–64 (Table 4).
Preventing Suicide among Men in the Middle Years
34
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Table 4. Suicide Death Rates per 100,000 by Means, 2014
Means Males (ages 18–34) Males (ages 35–64) Females (ages 35–64)
Firearms 10.84 14.52 2.92
Hanging (Suffocation) 8.29 7.57 2.02
Poisoning 1.70 3.85 3.57
All Means 22.70 28.13 9.29
Source: Data from Centers for Disease Control and Prevention (2014).
A study of suicides in workplaces in the United States (2003–2010) found that 84 percent of suicides in pro-
tective service workplaces (e.g., rst responders and animal control workers) involved rearms, compared to
50 percent of suicides in farming, shing, and forestry, and 29 percent among building and grounds cleaning
occupations (Tiesman et al., 2014).
Suffocation as a means of self-harm has been rising. Between 1999 and 2010, the percentage of suicides by
suffocation increased by 75 percent for men (i.e., from 18 to 24 percent) and by 115 percent for women (i.e.,
from 12 percent to 18 percent) (CDC, 2013).
Chronic Medical Conditions and Disability
Medical conditions associated with suicide include arthritis, cancer, asthma, peptic ulcers, cardiovascular dis-
ease, epilepsy, HIV, Huntington’s disease, chronic migraines, and multiple sclerosis (Berman & Pompili, 2011;
Webb et al., 2012). Although the research on the relationship between physical illness and disability and suicide
risk among MIMY is limited, many of these conditions begin to emerge as men enter this age range. For exam-
ple, the rates of heart disease, cancer, diabetes, and arthritis all start increasing when men (and women) are in
their 40s and continue to increase through older adulthood (Blackwell, Lucas, & Clarke, 2014).
The association between chronic medical conditions and suicide is often attributed to the fact that these con-
ditions can be associated with chronic pain (HHS, 2012; Tang & Crane, 2006; Webb et al., 2012). Schiff et
al. (2015) found that physical health conditions were one of four risk factors associated with suicides by men
between the ages of 35 and 64 who were not identied as having mental health or substance abuse problems,
which provides some evidence that chronic medical conditions can contribute to suicide risk even in the ab-
sence of depression. This research also found that suicides associated with health problems were more likely to
be triggered by a recent crisis after a period of long-term risk than by a crisis alone.
Disability has also been associated with suicide risk. NSDUH data from 2008 to 2013 (SAMHSA, 2013)
revealed that 30.4 percent of men, and 44.3 percent of women, ages 35–64 who attempted suicide within the
12 months preceding the survey were disabled and could not work. In this age group, 25.4 percent of men and
24.2 percent of women who had serious thoughts of suicide were also disabled and could not work.
Preventing Suicide among Men in the Middle Years
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SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Economic Factors
There is evidence that economic factors play a role in overall suicide rates, and especially among MIMY. For
example, NSDUH reveals that 39.3 percent of MIMY who attempted suicide had an income below the Federal
Poverty Line (SAMHSA, 2013).
Efforts to understand the relationship between suicide and socioeconomic status have been hampered by
the lack of income and income proxies in large databases such as the National Vital Statistics System and the
National Violent Death Reporting System. Educational attainment and occupational skill level are often used
as proxies for income and wealth in suicide research. Phillips (2010) found that suicide rates decreased with
educational attainment (Table 5).
Table 5. Suicide Rates per 100,000 for Men by Educational Attainment, 2005
Education Age: 40–49 years 50–59 years
12 or fewer years 34.89 31.03
13–15 years 17.65 18.55
16 or more years 13.46 16.61
Sources: Data from National Vital Statistics System and U.S. Census Bureau, as cited in Phillips (2010), Table 2.
The authors suggested that people with less education may be more at risk for suicide because of general
nancial strain and because they cannot afford care for chronic diseases that are associated with suicide risk.
Although the relationship between educational attainment and suicide also held for women, it was not as pro-
nounced as for men.
NSDUH data showed that although the risk of suicide attempts for MIMY is greater for high school graduates
than those who do not complete high school, this risk decreases with subsequent levels of educational attain-
ment (Table 6).
Table 6. Educational Indicators among Men and Women Who Reported
Suicidal Behaviors in the Past 12 Months, 2008–2013
Education
Men Attempts
(35–64 years)
Women Attempts
(35–64 years)
Men Serious
Thoughts
(35–64 years)
Women Serious
Thoughts
(35–64 years)
Less than High
School
29.5% 18.5% 17.6% 12.2%
High School
Graduate
33.7% 29.5% 31.9% 29.1%
Some College 22.5% 33.8% 25.5% 31.9%
College Graduate 14.3% 18.2% 25.1% 26.8%
Source: Data from the National Survey on Drug Use and Health, 2008-2013, Substance Abuse and Mental Health Services Administration (2013).
Preventing Suicide among Men in the Middle Years
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SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
The 18–34 age group was not included in this NSDUH analysis because a signicant number of members of that
age group will eventually complete high school or college (even if they had not done so at the time of the survey).
A meta-analysis (Milner, Spittal, Pirkis, & LaMontagne, 2013) found that people in low-skill-level occupations
were at a higher risk for suicide than people in high-skill-level occupations and the general working age popu-
lation. The greatest risk of suicide was among “elementary occupations,” including laborers and cleaners. The
occupational category that includes factory workers, machine operators, and ship’s crews also had a suicide
rate above that of the general population, as did police and skilled agricultural, forestry, and shery workers.
High-skill-level managers and clerical workers had the lowest rates of suicide. The authors suggested that “the
greater risk of suicide in lower skilled occupational groups may be symptomatic of wide social and economic
disadvantages, including lower education, income, and access to mental health services.
Suicide and “The Great Recession”
The economic downturn of the early 21st century—sometimes called the Great Recession—raised interest in
the relationship between economic crisis and suicide. Several large studies have revealed an association be-
tween an economic downturn and the suicide rate among men:
ñ Reeves et al. (2015) used data from the WHO Human Mortality Database to demonstrate that “male suicide
increases were signicantly associated with each percentage point rise in male unemployment, by 0.94% . . .
and indebtedness, by 0.54%” across 20 European Union member nations.
ñ Corcoran, Grifn, Arensman, Fitzgerald, & Percy (2015) concluded that “by the end of 2012, the male suicide
rate [in Ireland] was 57% higher . . . than if the pre-recession trend continued. The rate of self-harm among men
also increased signicantly. Most of these increases could be attributed to men 25–64 years of age.
ñ Nordt, Wanrke, Seifritz, & Kawohl (2015) conducted a 63-country analysis of suicide and unemployment
data and concluded that “the relative risk of suicide associated with unemployment was elevated by about
20–30%” during the Great Recession.
ñ Luo, Florence, Quispe-Agnoli, Ouyang, & Crosby (2011) found that in the United States “the overall suicide
rate and the suicide rates of the groups aged 25 to 34 years, 35 to 44 years, 45 to 54 years, and 55 to 64
years rose during contractions and fell during expansions.” Suicide rates among age groups not character-
istically employed (those 15−24, 65–74, and 75 years and older) were not associated with these economic
indicators. The analysis did not explore differences in rates between men and women.
The rising rate of suicide (and male suicide) in the United States noted in the Introduction coincided with the
economic problems that began with the bursting of the “dot com” bubble in 1999–2000 and continued through
the Great Recession of 2007–2012. Kaplan et al. (2015) concluded that suicide rates in the United States
increased by 7 percent during 2008–2011. This analysis also found that suicide rates for men ages 45–64
increased by 14 percent during that period (compared to 9 percent among women in that age group) and that
the percentage of suicides associated with alcohol intoxication increased 7 percent among both sexes.
Phillips and Nugent (2014) calculated that “a ve percentage point increase in the unemployment rate (which
was approximately the average increase in unemployment rates during the Great Recession) is associated with
an increase of about 10 percent in the total suicide rate.” They attributed this increase entirely to an increase in
the rate of suicide by people in the 45–64 age group.
Preventing Suicide among Men in the Middle Years
37
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Hempstead and Phillips (2015) found that the proportion of suicides in the United States (2005–2010) asso-
ciated with external circumstances (i.e., employment, nancial, and criminal and civil legal problems) increased
signicantly more than did suicides associated with personal or interpersonal circumstances. Most of this
increase occurred among both men and women ages 40–64 years and men of all ages. The percentage of sui-
cides associated with employment, nancial, and legal issues among people 40–64 years of age increased from
32.9 percent in 2005 to 37.5 percent in 2010. The authors suggested that the Great Recession “disproportionate-
ly affected the middle-aged in terms of house values, household nances, and hits to retirement accounts,” that
more workers in the middle years experienced decreases in their salaries than younger and older workers, and
that “the hardship and feelings of failure or hopelessness associated with these conditions are compounded by
the fact that middle-aged adults are more likely than others to be family breadwinners and supporting
dependents.
Houle and Light (2014) found that a ve percentage point increase in foreclosures in which the owners lost
their homes was associated with a 25 percent increase in the suicide rate in the 46–64 age group in the United
States. No signicant association between suicide and foreclosure was found for the 18–29 or the 65 and over
age groups. The authors pointed out that “losing key assets and wealth close to retirement age is likely to have
a profound effect on the mental health and well-being of middle-aged individuals.
An analysis using U.S. National Center for Health Statistics Detailed Mortality Files (Harper, Charters, Strumpf,
Galea, & Nandi, 2015) found an increase of about 1 percent in the rate of suicide as a consequence of the
Great Recession, which, as the authors pointed out, was much smaller than the increase identied by other
work on this topic. They did nd that the increase in suicides “was concentrated among men, middle-aged
groups, and those with the lowest education.
Milner, Hiven, and LaMontage (2015) found that an economic downturn increases disparities among suicide
rates among occupational groups. During the nancial crisis in Australia (2007–2009) “suicide rates in unskilled
workers such as labourers increased from three to six-fold greater than the rates in the highest class group,
while there was over a four-fold increase among technical and trade workers.” The authors theorized that this
might be because unemployment and job insecurity increases the most among lower-skilled workers during an
economic downturn.
Researchers and commentators (including Webb & Kapur, 2015) also noted that economic downturns create
stress among those who do not lose their jobs but experience reductions in income, increased workloads, debt,
and family conict resulting from economic insecurity.
Intimate Partner Problems
Intimate partner problems (e.g., divorce, separation, relationship discord) as well as intimate partner violence
have been shown to be risk factors for suicide.
A meta-analysis found that being a victim of intimate partner abuse (including physical violence and threatening be-
havior) is a signicant risk factor for suicidal thoughts and behavior in both men and women (McLaughlin, O’Carroll,
& O’Connor, 2012), although in the United States, women make up the bulk of the victims of such abuse.
Preventing Suicide among Men in the Middle Years
38
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Hempstead & Phillips (2015) found that men who died by suicide were signicantly more likely to have intimate
partner problems or to have perpetrated intimate partner violence than women in the same age range. A review
of the research literature (Evans, Scoureld, & Moore, 2014) concluded that “the weight of the reviewed studies
would seem to tentatively support the view that men are at greater risk of suicide than women following rela-
tionship problems, divorce, or separation.” Two of the authors suggested that the greater impact on men may be
due to their feeling of lost masculine identity, restrictions in contact with their children, loss of control over their
former wife/partner, and an overall lack of supportive social relationships that could buffer the effects of their
situation (Scoureld & Evans, 2015).
Schiff et al. (2015) found that intimate partner problems were “the most frequent type of precipitating circum-
stance experienced” in association with suicides of men between the ages of 35 and 64 who did not have
histories of mental health or substance abuse problems. Almost 60 percent of the men included in their study
had intimate partner problems (e.g., a divorce or argument) prior to their suicide. About half of the men had both
chronic (i.e., long-term) risk factors for suicide, as well as a crisis that precipitated their suicide. About half of
those who died after a crisis involving intimate partner issues were not found to have had any chronic (i.e., long-
term) risk for suicide. An indication of premeditation was found for almost 29 percent of the men with intimate
partner problems who died by suicide. The authors reported that “a common theme that emerged regarding
disclosure among this group was that men disclosed intent immediately prior to the suicide . . .
Cultural Expectations about Masculine Identity and Behavior and Suicide
A review of the research by Samaritans UK (Wyllie et al., 2012) found that the following factors contribute to
the disproportionate risk of suicide among MIMY (especially among low-income MIMY):
ñ Certain personality traits and mindsets (e.g., the need to meet others’ expectations, self-criticism, pessimism,
brooding, inadequate problem-solving abilities) and how these traits interact with triggering events (e.g.,
relationship breakdowns, job loss)
ñ A concept of masculinity dened by power, control, and invincibility
ñ The breakdown of relationships that deprive men of their primary source of emotional support and challenge
their self-image vis-à-vis masculinity
ñ Social disconnectedness resulting from a lack of ability to maintain peer relationships into the middle years
ñ Lack of emotional skills, especially those that enable a person to recognize and get help for emotional distress
A qualitative study of Australian men who had attempted suicide and families of men who attempted suicide
found that:
Almost all men reported that their masculine beliefs led to them isolating themselves when they were feeling
down, for example, to avoid imposing on others. Failure to manage emotions, or live up to expectations of
happiness or coping also often led to a sense of lost control or guilt, as well as anxiety about having these
perceived weaknesses or failures revealed. It was very common for family and friends to state that this
tendency of men to adopt typically masculine responses to distress meant that they were often unaware of
warning signs for suicide, or misinterpreted suicidality as depression or anger. (Player et al., 2015)
Preventing Suicide among Men in the Middle Years
39
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Coleman, Kaplan, and Casey (2011) concluded that adherence to this traditional concept of masculinity, psy-
chosocial stress, and easy access to lethal means is an especially dangerous combination.
Help-Seeking Behavior
Barriers to receiving effective behavioral health care is an established risk factor for suicide among people of
both sexes and all ages (HHS, 2012). These barriers include external circumstances such as the cost of be-
havioral health care. The research also suggests that MIMY face sex-specic barriers to accessing behavioral
health care that are associated with cultural expectations about masculine identity and behavior—most notably
the belief that it is not “manly” to seek or accept help for emotional problems or, for that matter, to seek or ac-
cept help for problems such as substance abuse, physical ailments, and nancial stress.
Men in the United States and other Western countries are signicantly less likely than women to seek profes-
sional help for mental and physical problems (Galdas, Cheater, & Marshall, 2005). The CDC’s National Health
Interview Survey found that fewer than half of adult men who feel anxious or depressed on a daily basis take
medication or seek help (Voelker, 2015).
NSDUH data also reveal that only 57.8 percent of men in the 35–64 age group who attempted suicide in the
12 months prior to being surveyed had received mental health treatment during that period. The percentage of
women in the 35–64 age group who had attempted suicide and received mental health treatment was 72.7 per-
cent. Using NVDRS data, Hempstead and Phillips (2015) found that women ages 40–64 who died by suicide
were signicantly more likely than men to have currently, or ever, been treated for a mental health problem. They
attribute this difference to a reluctance by men to seek mental health treatment (rather than to a lower preva-
lence of mental health conditions among men).
Rice et al. (2015) found that men who had previously sought help for mental health concerns were not more
likely to seek help for mental health issues in the future than men who had not sought help in the past. The
authors speculated that men’s role expectations created a barrier to help seeking even for men who had sought
help in the past.
There are also differences in the perceptions of the need for mental health treatment between men and women in
the 35–64 age group. NSDUH data (SAMHSA, 2013) reveals that men who attempted suicide were less likely to
think of themselves as being in need of mental health treatment than women (or in need of additional mental health
treatment, if they had received any). Also, 37.5 percent of the men who had attempted suicide in the 12 months
prior to the survey had neither received nor felt that they needed mental health treatment (Table 7).
Preventing Suicide among Men in the Middle Years
40
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Table 7. Mental Health Treatment and Perceived Mental Health Treatment
Needs of People (Ages 35–64) Who Attempted Suicide in the Past 12 months, 2008-2013
Treatment and Perception of Unmet Need Men
(35–64 Years of Age)
Women
(35–64 Years of Age)
Received Treatment and Did Not Perceive Unmet Need 34.7% 38.2%
Received Treatment But Perceived Unmet Need 23.1% 34.5%
Did Not Receive Treatment But Perceived Unmet Need 4.7% 6.1%
Did Not Receive Treatment and Did Not Perceive Unmet
Need
37.5% 21.2%
Source: Data from the National Survey on Drug Use and Health, 2008-2013, Substance Abuse and Mental Health Services Administration (2013).
In another analysis of data from NSDUH, Alang (2015) found that “while women were more likely to forego
mental health care because of cost, men were more likely to forego care because of stigma.” The association
between mental health care and stigma decreased with age as did men’s perceptions that (1) they could man-
age mental health problems without professional help or (2) mental health services would not be helpful.
Brownhill and Wilhelm (2002) suggest that men often respond to depression by seeking help for physical
symptoms (e.g., problems sleeping or chest pains) that could, in fact, be caused by their depression. This study
also found that men who consult a physician for physical symptoms resulting from emotional issues are more
likely to receive help for the mental health conditions than men who seek neither behavioral nor medical care.
Men can also be reluctant to seek help from friends, family, or other nonprofessionals (Berger, Addis, Green,
Mackiowiak, & Goldberg, 2013). A review of the literature by the American Association for Suicidology (n.d.)
suggested that men can perceive seeking help as conicting with the traditional male qualities of strength, inde-
pendence, and emotional control and that receiving help “requires a man to be vulnerable and to relinquish power
to another.” The authors suggest that men perceive help seeking as having “social costs”—that is, people will think
of them as incompetent (i.e., unable to solve their own problems), dependent (i.e., requiring anothers assistance),
and inferior to other men (because of their incompetence and dependence). They also suggest that “men who feel
connected to other men through traditional male gender roles may be more reluctant to seek help than men who
do not have this connection or men who are well connected to women.” This suggestion is supported by Berger et
al. (2013) who found that (1) men who were least concerned with adhering to masculine norms were most likely
to seek help from friends and family, and (2) men who valued emotional control were less willing to seek help from
friends and family than were men who did not place as high a value on emotional control.
The reactions of men who are reluctant to seek help for suicide risk or associated mental disorders can add to
their emotional burden. For example, Brownhill, Wilhelm, Barclay, and Schmied (2005) found that many men
attempt to cope with depression through self-medication (i.e., substance abuse) or distraction (e.g., risk-taking ac-
tivities, sexual encounters, aggressive and violent behavior, work, or extended periods of time watching television).
The Effectiveness of Behavioral Health Care for Men
There is evidence that behavioral health care, as currently practiced, may not be as effective at preventing sui-
cide among men as among women. For example, a study in the United Kingdom found that men in mental health
Preventing Suicide among Men in the Middle Years
41
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
care had a higher rate of suicide than the general population, which suggests that the higher rate of suicide
among men should not be entirely attributed to a lack of willingness to seek help (National Condential Inquiry
into Suicide and Homicide by People with Mental Illness, 2015).
Unfortunately, many evaluations of interventions to prevent suicide fail to report sex-specic results, which
is critical in light of the evidence that shows that interventions that effectively prevent suicide among women
may be less effective (or even ineffective) with men. One widely cited study of a Swedish program that trained
general practitioners in depression care showed a 60 percent decrease in suicides (Rutz et al., 1989). Later
analyses by sex revealed that this success was almost entirely due to a decline in suicides among women. The
program had virtually no effect on men (Rutz, von Knorring, Pihlgren, Rihmer, & Wålinder, 1995; Rutz, Wålinder,
von Knorring, Rihmer, & Pihlgren, 1997).
Similarly, a sex-specic analysis of randomized controlled trials of “caring contact” postcards sent to patients
seen for emergency care following self-injury found that their success at preventing future non-lethal self-injury
was entirely due to their effect on women. The postcards were not effective at reducing self-injury among men
(Carter, Clover, Whyte, Dawson, & D’Este, 2013). In what the authors referred to as “the largest follow-up study
of psychosocial therapy interventions after deliberate self-harm [i.e., suicide attempts],” a long-term research
project in Denmark found that psychosocial interventions signicantly reduced subsequent suicide attempts,
as well as overall general mortality, among women, but not men. This research also reported that psychosocial
interventions benet people between 10 and 24 years of age more than older adults (Erlangsen et al., 2015).
The ability of psychotherapy to prevent suicidal behavior in MIMY remains largely unstudied. Although clinical
trials demonstrate that dialectical behavior therapy (DBT) can prevent suicide attempts (Linehan et al., 2006), a
meta-analysis (Kliem, Kröger, & Kosfelder, 2010) revealed that 95 percent of the participants in these trials were
women. Little evidence exists for the effects of DBT on men. Furthermore, studies that showed that cognitive
behavior therapy can prevent suicide attempts (Rudd et al., 2015) and that the Collaborative Assessment and
Management of Suicidality can reduce suicidal ideation (Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005)
among men use samples that were primarily composed of younger men.
New Patterns of Suicide Risk
An analysis of suicide rates among Americans born after 1915 by Phillips (2014) suggests that the increased
rate of suicide seen among the contemporary generation of Americans in the middle years (i.e., “baby boomers”)
may reect:
1. The end of a period in the late 20th century when specic historical conditions (e.g., the relative youth of the
population, economic prosperity, and the use of new types of antidepressants) led to lower suicide rates
2. The aging of the baby-boom cohort (and especially men) into a period of life when suicide rates are tradi-
tionally higher than for younger people
Preventing Suicide among Men in the Middle Years
42
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
3. Social and economic changes that weaken social integration and regulation, including:
ñ An increase in the percentage of the population that lives alone (a consequence of rising divorce rates and
declining marriage rates)
ñ A decline in religious involvement
ñ Declining levels of civic participation (i.e., social connectedness)
ñ Rising obesity rates (which contribute to chronic health conditions that are risk factors for suicide)
ñ An unstable economy and changes in employment patterns that make it difcult for MIMY to nd jobs after
they are laid off
ñ Technologies (such as social media) that change the ways in which people communicate and interact, which
may increase, rather than decrease, feelings of isolation
ñ Rising rates of mental disorders that may themselves reect social changes
Phillips suggests that while these social and economic changes may contribute to an increase in the suicide
rate for both sexes, they may be particularly problematic for men, as (1) changes in employment patterns are
especially challenging for MIMY and (2) men may experience stress and psychological isolation in response to
changes in gender roles that challenge the dominant role of men in social relations (including marriage) and the
economy.
Overarching Issues
The National Strategy for Suicide Prevention states that “there is no single path that will lead to suicide. Rath-
er, throughout life, a combination of factors, such as a serious mental illness, an alcohol use disorder, a painful
loss, exposure to violence, or social isolation may increase the risk of suicidal thoughts and behaviors” (HHS,
2012). This conclusion is borne out by research such as that of Player et al. (2015) that identied four factors
that “tended to interact with each other and worsen over time, leading to greater suicide risk, while also creat-
ing barriers that interfered with attempts to treat depression or interrupt suicidality:” (1) depressed or disrupted
mood; (2) “unhelpful conceptions of masculinity consisting of stoic beliefs and values, which strongly inuenced
decision-making;” (3) “social isolation and use of other avoidant copying strategies,” and (4) “at least one, but
often many, personally meaningful stressors.
Thus, it is combinations of risk factors that are especially dangerous and can raise the risk of suicide more than
any individual risk factor. All things being equal, a man who is socially isolated, suffers from major depressive
disorder, and has access to a rearm is at greater risk for suicide than a man who has access to a rearm but is
not depressed and has a social support system (e.g., family, colleagues, and friends). Risk factors can also work
in the short term to precipitate or “trigger” a suicide. An unexpected job loss might trigger a suicide attempt in
a man who suffers from major depression and is socially isolated but not in a man who was not depressed and
has a social support system.
Preventing Suicide among Men in the Middle Years
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SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Protective Factors for Suicide among Men in the Middle Years
The research on protective factors is far less robust than the research on risk factors (Beautrais, Collings,
Ehrhardt, & Henare, 2005). Major protective factors for suicidal behaviors for people of both sexes and all ages
include the following:
ñ Access to effective health care (including effective behavioral health treatment) (HHS, 2012; Suicide Preven-
tion Resource Center [SPRC] & Rodgers, 2011)
ñ Social connectedness to individuals, including friends and family, and to community and social institutions
(CDC, n.d.; HHS, 2012; SPRC & Rodgers, 2011)
ñ Coping and problem-solving skills (HHS, 2012; SPRC & Rodgers, 2011)
ñ Reasons for living, meaning in life, and purpose in life (Kleiman and Beaver, 2013)
Although not much research has been done on the impact of reasons for living, meaning in life, and purpose in life
on MIMY, a study of both sexes and several age cohorts (including 40–64 years of age) concluded that “presence
of meaning in life predicted decreased suicidal ideation over time and lower lifetime odds of a suicide attempt”
(Kleiman and Beaver, 2013). Reasons for living, meaning in life, and purpose in life have been found to confer
some protection against suicidal behaviors in clinical samples (Garcia-Alandete, Marco, & Perez, 2014; Heisel &
Flett, 2004), older adults (Heisel, Neufeld, & Flett, 2015), members of the armed forces (Bryan et al., 2013; Bryan,
Graham, & Roberge, 2015), and college students (Wang, Lightse, Pietruszka, Uruk, & Wells, 2007).
Marriage (a social connection) was found particularly protective for MIMY. A long-term study (Tsai, Lucas, Sa-
nia, Kim, & Kawachi, 2014) of men ages 40–75 found that social integration (measured at baseline) was asso-
ciated with a two-fold reduction in suicide risk over 24 years. Measures of social integration included marital
status, social network size, frequency of social contact, religious participation, and participation in other social
groups. Social network size, religious service attendance, and marital status were found to have the stron-
gest effects. Both family and religious integration were shown to be protective in-and-of themselves. Marriage
also seems to provide some protection against suicide for men. Phillips (2010) found that “in 2005, unmarried
middle-aged men were 3.5 times as likely to die from suicide as married middle-aged men” She also found that
the suicide rate among unmarried men in the 40–49 and 50–59 age groups (51.04 and 51.97/100,000) was
markedly higher than the rate for unmarried women of the same ages (14.16 and 12.01).
Suggestions from the Research Literature on Preventing Suicide
among Men in the Middle Years
This section summarizes the suggestions made by researchers and practitioners about preventing suicide
among MIMY. Specic programs that are currently being implemented to address suicide among MIMY are
described under Programs and Resources (below).
The material in this section was drawn from the research on suicide among men in the middle years with
special emphasis on a few reports that included explicit recommendations about preventing suicide among
men in the middle years or men general. We did not systematically review the evidence provided for these
recommendations given that they appeared in articles and reports authored by reputable researchers and
organizations.
Preventing Suicide among Men in the Middle Years
44
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Many of the suggestions made by researchers and practitioners for preventing suicide among MIMY (and
men in general) encompass expanding and better targeting interventions and strategies that are generally
endorsed as effective by the eld of suicide prevention such as the following:
ñ Training primary care physicians to diagnose and treat depression (Wyllie et al., 2012)
ñ Improving referrals to behavioral health specialists (Wyllie et al., 2012)
ñ Integrating suicide prevention into substance abuse treatment (Wyllie et al., 2012)
ñ Targeting men at highest risk for suicide for intervention (Spencer-Thomas, Hindman, & Conrad, 2012)
We will forego an extended review of what works in suicide prevention in general in favor of a discussion of
what has been recommended specically for adult men.
Apply Cultural Competence to Suicide Prevention for Men
Much of the literature on men and suicide contains an implicit theme that says, in the words of Help-
Seeking among Men: Implications for Suicide Prevention, “It is tempting to argue that one way to increase
help-seeking behavior among men would be to become less constrained by gender role expectations”
(American Association of Suicidology, n.d.). At the same time, there is a reluctance to engage in the daunt-
ing task of creating a cultural shift of this magnitude. Thus, the authors of Help-Seeking among Men:
Implications for Suicide Prevention (American Association of Suicidology, n.d.) concluded that the research
“strongly recommends” that suicide prevention activities for men be framed in the context of traditional mas-
culine values, such as competence, achievement, and self-reliance rather than attempt to change social role
expectations, and that public health messaging should do the following:
1. “Emphasize the social benets of help-seeking” and assert that help seeking demonstrates that a man is
courageous, competent, independent, and in control—and thus, masculine
2. Promote self-care as part of a man’s responsibility as provider and caretaker for his family
3. Frame help seeking as a cognitive problem-solving task
4. Dene men’s problems in terms of external causes rather than internal weakness
5. Provide men with information rather than confront them about their problems
Suggestions from the Research Literature (continued)
Preventing Suicide among Men in the Middle Years
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SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Suggestions from the Research Literature (continued)
Oliffe and Han (2014) suggest using “strength-based approaches trading on masculine ideals of problem
solving and provider and protector roles [that] engage men with their health on their own terms.” These ap-
proaches include (a) using “positive messaging to promote change without amplifying stigma, guilt, shame,
and blame;” (b) “fostering connections between masculine ideals (e.g., strength, decisiveness, resilience,
autonomy, rationality) and health;” and (c) incorporating testimonials of men. Spencer-Thomas et al. (2012)
also take this approach and recommend using messages that emphasize self-reliance and self-help rather
than help seeking as well as teaching intimate partners, coworkers, and others how to recognize and re-
spond to suicide risk in men.
There is some tension between (1) the research that shows that traditional masculine values and identity
contribute to suicide risk and (2) suggestions to leverage these values to prevent suicide. Fleming, Lee, and
Dworkin (2014) point out that the traditional gender norms can “encourage violent or sexually domineering
behavior” as well as contribute to negative physical and mental health outcomes for men. A study of Cana-
dian men “found that, among male-middle-aged workers, masculinity ideology appeared to be most often a
risk factor for health, rather than a protective factor . . . .” (Houle et al., 2015).
Develop or Adapt Psychotherapies for Men
A number of experts have concluded that psychotherapeutic interventions used to treat suicidality or related
issues (such as depressive symptoms) need to be adapted to be more acceptable to and effective with men,
for example by:
ñ Presenting concepts such as anxiety and depression in ways that reduce perceived stigma (Berger et al.,
2013)
ñ Developing modes of help seeking that men perceive as preserving their autonomy (Berger et al., 2013)
ñ Presenting interventions as “training” rather than “therapy” (Spencer-Thomas et al., 2012; Wyllie et al.,
2012)
ñ Using “masculine scripts” in therapy that respond to a male patient’s personal characteristics and
self-image (e.g., “strong and silent,” tough guy,” “winner”) (Mahalik, Good, & Englar-Carlson, 2003)
A qualitative study that interviewed men who had attempted suicide as well as the families of men who at-
tempted suicide (Player et al., 2015) suggested that interventions that successfully interrupted men’s paths to
suicide attempts should target four core features of male suicidality: “disrupted mood, unhelpful stoic beliefs
and values, avoidant coping strategies, and stressors.” The analysis also suggested that interventions should
respond to the level of risk of individuals. Acute/immediate risk can be interrupted with distraction, practical
and emotional support, and professional health intervention. Less immediate but recurrent suicidal ideation
was found to be interrupted by reminders of how a man’s suicide would affect family and friends, and espe-
cially his children, as well as by providing men with strategies to help them respond to the stressors that trig-
ger suicidal thoughts and regulate their emotions when under stress. In addition, Player et al. (2015) stated:
Preventing Suicide among Men in the Middle Years
46
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Suggestions from the Research Literature (continued)
Men reported beneting from regular contact with a person, with whom they could discuss problems,
providing space to ventilate and address distress. They identied that respect for, or having trust in these
support persons was crucial, and they could be more benecial if they are outside the immediate family.
The authors also stated that efforts to prevent suicide among men should incorporate the unique roles that
different groups of people (e.g., friends, family, and mental health professionals) could play in interrupting
a man’s path toward attempting suicide. These roles will vary depending on (1) a man’s level of risk, (2)
contributing risk factors (e.g., substance abuse or mental illness), and (3) cultural differences that affect the
types of people from whom a man will accept help.
Use Venues and Modalities that Appeal to Men
Other suggestions for preventing suicide among men include these:
ñ Implementing prevention activities in venues in which men are traditionally found (e.g., workplaces, job
training programs, and sporting events) (American Association of Suicidology, n.d.; Prevention Institute,
2014; Spencer-Thomas et al., 2012; Wyllie et al., 2012). It has also been suggested that criminal justice
settings and civil court settings may provide a strategic venue for intervening, given the elevated risk of
these men, and the fact that men in these settings often feel vulnerable and want, and will accept, help
(Catherine Cerulli, personal communication, 2015).
ñ Conducting gatekeeper training for people who characteristically come into contact with men who may be at
risk for suicide (e.g., bartenders, divorce or bankruptcy attorneys) (American Association of Suicidology, n.d.).
ñ Promoting social connectedness through activities that involve “doing” (e.g., hobbies, sports) rather than
“talking” (Wyllie et al., 2012).
Intervene Earlier in Men’s Lives
Although this publication focuses on suicide prevention interventions that target men when they are in their
middle years, interventions directed at boys, adolescents, and young men play an important role in reducing
the risk that men face when they enter the middle years, as well as enhancing the resilience of men that will
help them face the challenges of that period in their lives.
Regulate Access to Highly Lethal Means
The authors of two recent studies on handgun regulation and suicide (Anestis & Anestis, 2015; Anestis et
al., 2015) found that each of seven types of state laws regulating handguns were individually associated
with signicant reductions in suicide. These laws included the following:
ñ Permits to purchase handguns
ñ Handgun registration
ñ Licenses to own handguns
Preventing Suicide among Men in the Middle Years
47
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
ñ A waiting period before a handgun sale can be completed and the buyer can take possession of the handgun
ñ A background check before a handgun permit can be issued or before a handgun can be transferred from
one person to another
ñ Handguns to be locked under at least some circumstances
ñ Regulating the open carrying of handguns
The results were not broken down by age or sex. The analysis did not include long guns because they are
less frequently used in suicides than handguns.
A review of the research on rearm ownership rates, suicide rates, and policy-based strategies for prevent-
ing rearm suicides concluded that “rearms restrictions, including permit to purchase (PTP), waiting peri-
ods, safe storage, background checks, and registration guidelines, are associated with both lower rearm
suicide rates and overall suicide rates.” (Mann & Michel, 2016)
Address Socioeconomic Risk Factors that Contribute to Suicide Risk
Li, Page, Martin, and Taylor (2011) conducted a systematic review and meta-analysis of suicide research (all
ages, both sexes, several countries) that included socioeconomic data, and they concluded the following:
ñ Mental illness places an individual at far higher risk of suicide than does lower socioeconomic status.
ñ However, the number of suicides associated with lower socioeconomic status is about the same as the
number of suicides associated with mental illness, because there are more people of lower socioeconomic
status than there are people with mental illness.
They concluded that interventions that successfully address suicide risk associated with low socioeconomic
status would be as effective at reducing the overall suicide rate as would interventions that successfully ad-
dress suicide risk associated with mental disorders. This would be especially true for MIMY, as the association
between socioeconomic status and suicide risk is stronger for men than for women and for MIMY than for
younger men.
Reeves et al. (2015) suggested that the results of their multi-country study of suicide during the global
economic crisis (summarized earlier) implied that “spending on active labor market programs and high
levels of social capital moderated the unemployment-suicide association.” This spending helped limit the
impact of the economic downturn on suicides in some European countries, compared to the United States
in which there is less direct intervention in the labor market and less of a “safety net” for people affected by
economic downturns.
Suggestions from the Research Literature (continued)
Preventing Suicide among Men in the Middle Years
48
SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
Conclusion
This review was based upon the research on suicide among men in the middle years published between 2005
and 2015. It also includes several articles published before and after this period that came to our attention and
seemed especially notable. Some of the information presented in the review of the research came from an anal-
ysis of data from SAMHSAs National Survey on Drug Use and Health (NSDUH). The material in Suggestions
from the Literature on Preventing Suicide among Men in the Middle Years was also drawn from these sources.
The material in the review of the research was used as background information for the discussions among the
project staff, advisory group, and representatives of the funding agency. These discussions and deliberations
were the basis for developing the key points and recommendations that appear at the beginning of this publi-
cation. It should be noted that the key points and recommendations do not represent a structured weighing of
the evidence found in the literature nor was a strict consensus reached among the participants in the discus-
sions that informed this publication. However, we hope they will encourage and guide efforts to prevent suicide
among men in the middle years, which is an important endeavor in and of itself as well as an essential step in
reducing the overall rate of suicide in the United States.
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SECTION 3: A Review of the Research on Suicide among Men in the Middle Years
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press/Men%20Suicide%20and%20Society%20Research%20Report%20151112.pdf
SECTION 4
Programs and Resources
Preventing Suicide among Men in the Middle Years
55
SECTION 4: Programs and Resources
This section contains information on available programs and resources that
are relevant to suicide prevention among men in the middle years (MIMY). A
summary table is provided, followed by written descriptions and links to online
information. Both the table and the list of descriptions are in alphabetical order
by the program or resource name.
Although this list is not exhaustive, it contains key programs and resources that
were available at the publication of this report that may be useful in addressing
both the suicide risk and protective factors among MIMY described in this re-
port and the implementation of the recommendations. Note that the programs
and resources included here have not been endorsed by SPRC.
Some of these programs and resources were designed specically for MIMY
or all adult males, and some were designed for a broader population but can
be modied to focus on MIMY. Most will need to be adapted to serve a partic-
ular portion of the MIMY population within a particular setting. In addition, state
and community programs are likely to have prevention efforts underway that
they can adapt for MIMY in their area.
At this time, there is very little research evidence showing the effectiveness of these programs and resources
with MIMY. Only about a third of the programs and resources listed here have been studied or evaluated in any
way, and very few have been evaluated for their effectiveness in preventing or reducing suicide. However, some
have been studied to determine outcomes such as increases in knowledge, changes in beliefs and attitudes,
and self-efcacy in working with people who are suicidal. In addition, only a small number of the studies have
been published in peer-reviewed journals. When an evaluation or other study is available online, the name and
link have been included at the end of the description of the program or resource.
Programs and Resources Table
This table crosswalks the programs and resources in this section with the recommendations outlined at the
beginning of this report.
Program/Resource Name Brief Program Description
Related Recommendation
Number(s)
Breaking the Silence (USA) Report, video, and guide to prevent suicides of
police ofcers
12
Campaign Against Living Miserably
(CALM) (UK)
Website, phone helpline, and Web chat to help men
who are depressed or in crisis and to encourage
help seeking
3, 6, 7, 13
Caring for Adult Patients with
Suicide Risk: A Consensus Guide for
Emergency Departments (USA)
Guide to assist ED health care professionals with
treatment and discharge of patients at risk for
suicide
5
Comprehensive Blueprint for
Workplace Suicide Prevention (USA)
Overview of a comprehensive approach to
workplace suicide prevention, and lists of resources
12
An effective population-
based suicide preven-
tion program should use
multiple interventions
to address the multiple
factors that put people
at risk. A comprehensive
approach is as central
to preventing suicide
among MIMY as it is to
addressing the overall
suicide problem in a
community, a state, or
the nation as a whole.
Preventing Suicide among Men in the Middle Years
56
SECTION 4: Programs and Resources
A Construction Industry Blueprint:
Suicide Prevention in the Workplace
(USA)
Guide to help construction industry workplaces
address suicide
12
Continuity of Care for Suicide
Prevention: The Role of Emergency
Departments (USA)
Recommendations and key steps for managing ED
patients at risk for suicide
5
Counseling on Access to Lethal Means
(CALM) (USA)
Online training for providers on counseling patients
and families on reducing access to lethal means
4, 5, 6, 9
Dude’s Club (Canada) Program to reduce risk for depression and suicide
and to promote wellness among First Nations men
3, 15
Gatekeepers of Middle Aged Men
(USA)
In-person training to help clinicians prevent suicide
among middle-aged men
6
HeadsUpGuys (Canada) Website with information and resources to
encourage help seeking among men at risk for
depression and suicide
3
Make the Connection (USA) Website with resources on mental health and
substance abuse for veterans and their families,
friends, and clinicians
3
Man Therapy (USA) Website encouraging working-age men to seek
help for mental health issues
3
MassMen.org (USA) Website connecting men to Man Therapy and
resources in Massachusetts
3
MATES in Construction (Australia) Comprehensive workplace program for the
construction industry to reduce suicide risk
12
Meaning-Centered Men’s Groups
(Canada)
Groups for retiring men over age 55 to reduce risk
of depression and suicide
6, 15
Men at Risk (Canada) Presentations for men in workplaces and
communities to reduce suicide risk and encourage
help seeking
3, 12
Men’s SHARE (Suicide, Harm,
Awareness, Recovery and Empathy)
(Scotland)
Weekly support groups that help men ages 25–50
connect with other men, access help, develop
resilience, and engage in meaningful activities
3, 15
Men’s Sheds (Australia, New Zealand,
Ireland, UK, Canada)
Program for men (often unemployed or retired)
to connect with other men, learn skills, work on
projects, and gain information
3, 15
MensLine (Australia) Phone and online information and support for men,
particularly on family and relationship issues
6, 11
Mind Our Men (Ireland) Suicide prevention public awareness campaign
encouraging women and men to help male friends
and family members nd services
3, 13
The Mission Continues (USA) Program to help veterans reintegrate through
community service work
15
Preventing Suicide among Men in the Middle Years
57
SECTION 4: Programs and Resources
Mojo Programme (Ireland) 12-week training program for unemployed men to
increase mental health and wellness
11, 15
National Suicide Prevention Lifeline
(USA)
Suicide prevention hotline and Web chat 6, 7
Oz Help Foundation (Australia) Comprehensive workplace program to reduce
suicide risk; often used in male-dominated
workplaces
12
Real Warriors Campaign (USA) Public awareness campaign and website to support
reintegration and help seeking among veterans and
their families
13
The Role of Adult Correctional Ofcers
in Preventing Suicide (USA)
Information sheet to help adult correctional ofcers
prevent suicides among inmates
10
Safety Planning Guide: A Quick Guide
for Clinicians (USA)
Brief guide to help clinicians develop safety plans
with patients at risk of suicide
4, 5, 6
SBIRT: Screening, Brief Intervention,
and Referral to Treatment (USA)
Website with resources for implementing SBIRT to
address substance abuse problems
8
Sequential Intercept Model (SIM)
(USA)
Conceptual framework for working with people with
behavioral health disorders who are in the criminal
justice system
10
Soften the Fck Up (Australia) Mass media campaign encouraging young men to
seek help for mental health issues
3, 13
Suicide Action Montreal (Canada) Telephone and face-to-face crisis services,
including for friends and family of men at risk for
suicide
6, 7
Suicide Prevention: A Role for Firearm
Dealers and Ranges (USA)
Educational program for gun shops and ring
ranges
9
TIP 50: Addressing Suicidal Thoughts
and Behaviors in Substance Abuse
Treatment (USA)
Manual with guidelines and training video for
substance abuse treatment counselors working
with suicidal adults
8
TIP 56: Addressing the Specic
Behavioral Health Needs of Men
(USA)
Manual with guidelines for clinicians specic
to working with adult men with substance use
disorders
3, 8
Together for Life (Canada) Comprehensive suicide prevention program for
police departments to prevent ofcer suicides
12
Value Options: Strategy in Workplace
Suicide Prevention (USA)
Website containing information and resources for a
workplace suicide prevention program
12
Veterans Crisis Line (USA) Phone crisis line, online chat, and text for veterans,
service members, and their families and friends
6, 7
Working Minds (USA) Comprehensive workplace suicide prevention
program often used in workplaces employing
substantial numbers of men
12
Preventing Suicide among Men in the Middle Years
58
SECTION 4: Programs and Resources
Your Voice Counts Resource Center
(USA)
Suicide prevention mass media campaign with
materials targeted at MIMY
13
Zero Suicide (USA) Suicide prevention strategies and tools for health
and behavioral health care organizations
4, 6
Programs and Resources List
Breaking the Silence (USA)
ñ Report: Breaking the Silence on Law Enforcement Suicides
http://www.theiacp.org/portals/0/documents/pdfs/suicide_project/ofcer_suicide_report.pdf
ñ Video: Breaking the Silence: Suicide Prevention in Law Enforcement
https://www.youtube.com/watch?v=fBJbo7mnnBs&feature=youtu.be
ñ Video Facilitation Guide: Breaking the Silence: Suicide Prevention for Law Enforcement http://actionalliance-
forsuicideprevention.org/sites/actionallianceforsuicideprevention.org/les/LEGuide.pdf
These materials address suicide prevention among police ofcers. The report outlines strategies and provides
resources for police departments to use in promoting mental wellness, preventing suicides, and responding to
mental health crises and suicides among police ofcers. The video features ofcers talking about their expe-
riences and encourages other ofcers to seek help when feeling emotionally distressed or suicidal. The video
facilitation guide is designed to help facilitate discussions when showing the video to different law enforcement
audiences, from line staff to supervisors to command staff.
Campaign Against Living Miserably (CALM) (UK)
https://www.thecalmzone.net/
CALM offers support to men who are depressed or in crisis through a telephone hotline and Web chat, a
website, and an online magazine. The program works with health commissions to promote its message at local
events and venues. In partnership with other groups, it pushes for changes in policies and practices to prevent
suicide.
Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments (USA)
http://www.sprc.org/ed-guide
This guide is designed to assist Emergency Department (ED) staff with decisions about the care and discharge
of patients at risk for suicide and to improve patient outcomes after discharge. The guide helps ED caregivers
intervene appropriately, decide if the patient can be discharged or if further evaluation is needed, and ensure
that the patient will be safe after leaving the ED.
Comprehensive Blueprint for Workplace Suicide Prevention (USA)
http://actionallianceforsuicideprevention.org/task-force/workplace/cspp
This Web-based resource provides an overview of a comprehensive approach to suicide prevention that can be
used in a wide variety of workplaces and industries, and suggests a number of resources that can be used to
implement this approach.
Preventing Suicide among Men in the Middle Years
59
SECTION 4: Programs and Resources
A Construction Industry Blueprint: Suicide Prevention in the Workplace (USA)
http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/les/Suicide%20Pre-
vention%20in%20the%20Workplace%20-%20Final.pdf
This guide was designed to help leaders, managers, and supervisors in the construction industry implement
suicide prevention activities in their workplaces. It includes information about suicide and suicide prevention tai-
lored to the construction industry, a checklist to determine if a company’s environment is contributing to suicide
risk, suicide prevention presentations that managers can give to employees, guidance about how workplaces
can be used to reduce suicide risk, and information on resources.
Continuity of Care for Suicide Prevention: The Role of Emergency Departments (USA)
http://www.sprc.org/sites/sprc.org/les/library/ContinuityCare_Suicide_Prevention_ED.pdf
This short publication highlights key steps that ED providers can take to establish continuity of care for patients
at risk for suicide and to prevent suicides and attempts after discharge.
Counseling on Access to Lethal Means (CALM) (USA)
http://training.sprc.org/
This online training is designed for providers who counsel people at risk for suicide—primarily mental health and
medical providers, but also clergy and social service providers. The rst module explains why reducing access
to lethal methods of self-harm saves lives; the second module teaches practical skills on when and how to ask
clients about their access to lethal means and how to work with them and their families to reduce access to
means of self-harm.
Dude’s Club (Canada)
http://www.dudesclub.ca/
This British Columbia-based program provides events and activities that focus on spiritual, physical, mental,
emotional, and social aspects of wellness for First Nations men, with the larger goal of reducing depression and
suicide through culturally appropriate activities. It also helps First Nations men identify health and mental health
services and reconnect with their traditional roles.
Gatekeepers of Middle Aged Men (USA)
http://www.fsmv.org/Samaritans/GatekeeperTrainings.html
This two-hour training helps clinicians reduce the incidence of suicide among men ages 35–64 in Massa-
chusetts. Participants learn how to identify risk and protective factors and warning signs, ask questions about
suicide risk, develop a safety plan, and provide MIMY with resources. CEUs are available for social workers,
licensed mental health counselors, and licensed alcohol and drug counselors.
HeadsUpGuys (Canada)
http://headsupguys.ca
This website for men features information on identifying and reducing depression and preventing suicide. It
includes a self-check tool, videos in which men share their stories and coping tips, resources for seeking help,
and a form that men can use to create an action plan for recovery. It also includes information on how friends
and family can provide support to men experiencing depression.
Preventing Suicide among Men in the Middle Years
60
SECTION 4: Programs and Resources
Make the Connection (USA)
http://maketheconnection.net/
This website features information on mental health, substance abuse, and life issues that are relevant to veter-
ans and their families, friends, and clinicians. It also has videos in which veterans tell their stories and informa-
tion on resources for further help both within and outside the Veterans’ Administration.
Man Therapy (USA)
http://www.mantherapy.org
Man Therapy is an interactive website that encourages men to consider their own behavioral health needs and
seek help for themselves, and to encourage other men to seek help when needed. Men can interact with a
ctional therapist, do a self-assessment, and get mental health tips. If they need further help, they are referred
to the National Suicide Prevention Lifeline or a list of professional mental health providers. Information about the
development and use of Man Therapy can be found at the Carson J. Spencer Foundation website: http://car-
sonjspencer.org/les/6014/1013/1285/ManTherapyWhitePaper.02.12.2014.pdf
MassMen.org (USA)
http://massmen.org/
Through this website, Massachusetts working-age men and their loved ones can access Man Therapy (see
above), online self-assessments, and information on mental health resources in Massachusetts.
MATES in Construction (Australia)
http://www.matesinconstruction.org.au
This program for the Australian construction industry provides training and support, with the overarching goal of
preventing suicide and improving mental health and well-being. It includes a General Awareness Training for all
employees and Connector and ASIST gatekeeper trainings. Support services are also provided by trained profes-
sionals through a 24/7 Help Line and case managers who help employees obtain behavioral health services. Post-
vention is also available. More information about the impact of this program can be found in the following papers:
Footprints Market Research. (2012, December). MATES in Construction program evaluation: Report of ndings.
Retrieved from http://matesinconstruction.org.au/wp-content/uploads/2016/03/2012-MIC-Program-Evalutation.pdf
Doran, C. M., Ling, R., & Milner, A. (2015, August). The economic cost of suicide and non-fatal suicidal behaviour in
the Australian construction industry by state and territory. Retrieved from http://matesinconstruction.org.au/wp-content/
uploads/2016/03/Cost-of-suicide-in-construction-industry-nal-report.pdf
Meaning-Centered Men’s Groups (Canada)
https://ca.movember.com/report-cards/view/id/3259
“Enhancing Psychological Resiliency in Older Men Facing Retirement: Testing a Meaning-Centered Group In-
tervention” is designed to enhance men’s sense of meaning in life, mental health, and well-being and to reduce
the onset of depression and suicide risk in men facing retirement. Groups of 10–12 soon-to-be or newly retired
men age 55 or older meet weekly with facilitators in a community location. The sessions produce a sense of
community among men and address retirement-related challenges and opportunities.
Men at Risk (Canada)
http://www.sp-rc.ca/programs/tough-enough-to-talk-about-it
This one-hour gatekeeping program provided by the Suicide Prevention Resource Centre in Canada teaches
people to recognize and respond to mental health problems in men working in the trades, industry, or agricul-
ture. Update: The Men at Risk program has been replaced with the program Tough Enough to Talk About It.
Preventing Suicide among Men in the Middle Years
61
SECTION 4: Programs and Resources
Men’s SHARE (Suicide, Harm, Awareness, Recovery and Empathy) (Scotland)
http://www.health-in-mind.org.uk/services/orchard-centre-services/SHARE.html
This project sponsors weekly drop-in support groups that provide man (ages 25–50) with opportunities to dis-
cuss emotional issues, develop resilience strategies, and engage in activities that promote a sense of purpose
and belonging (e.g., joining a football team, taking a lm course).
LeMaigre, C., Murphy, J., & Bird, M. (n.d.). The Men’s SHARE project – an evaluation. Retrieved from http://www.
health-in-mind.org.uk/assets/les/2014%20Mens%20Share%20report.pdf
Men’s Sheds (Australia, New Zealand, Ireland, UK, Canada)
ñ Australian Men’s Shed Association (AMSA): www.mensshed.org
ñ Mensheds Australia: http://www.mensheds.org.au/
ñ MENZSHED New Zealand: http://menzshed.org.nz/
ñ Irish Men’s Sheds Association: http://menssheds.ie/about-us/
ñ UK Men’s Sheds Association: http://www.menssheds.org.uk/
ñ Canadian Men’s Sheds Association: http://menssheds.ca
Men’s Sheds are community-based organizations that provide a safe and friendly environment for men to learn
practical skills, develop new interests, work on meaningful projects (e.g., carpentry, restoring bicycles for a local
school, gardening, art), connect with other men, and talk about their problems. Some Men’s Sheds incorporate
visits from health care professionals and access to men’s health literature. There is wide variation in the focus of
different sheds, but most aim to advance the well-being and health of members and decrease social isolation.
Although the Sheds tend to draw older men who are unemployed or retired, they are open to men of all ages.
Men’s Sheds associations represent and promote the Shed movement. More information on Men’s Sheds can
be found here:
Wilson, N. J., & Cordier, R. (2013). A narrative review of Men’s Sheds literature: Reducing social isolation and
promoting men’s health and well-being. Health & Social Care in the Community, 21(5), 451–463. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/hsc.12019/full
Canadian Men’s Sheds Association. (2016). Men’s Sheds Canada: A toolkit for starting & growing sheds. Retrieved
from http://menssheds.ca/the-toolkit
MensLine (Australia)
http://www.mensline.org.au/
The MensLine is a free professional telephone and online support and information service specializing in family
and relationship issues, including relationship breakdown, separation and divorce, parenting, family violence,
and emotional well-being. Counseling sessions are usually about 30 minutes. The MensLine also offers online
forums for men, wives and partners, and rural men.
Mind Our Men (Ireland)
http://www.mindourmen.ie/
This public awareness campaign encourages both women and men to recognize signs of emotional distress in
the men in their lives and to help emotionally distressed men obtain behavioral health services. Mind Our Men
is operated by Pieta House, an organization that provides help for people in suicidal crisis or who are engaging
Preventing Suicide among Men in the Middle Years
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in self-harming behaviors. Pieta House’s related Mind Ur Buddy program has partnered with the Construction
Industry Federation to launch Mind Our Workers, and with the Irish Farmers’ Association to sponsor Mind Our
Farm Families.
The Mission Continues (USA)
https://www.missioncontinues.org/
This program supports veterans who are reintegrating into the civilian environment by engaging them in commu-
nity service, which provides them with a renewed sense of purpose in life, a stronger social network, profession-
al development support, and the broader health benets of serving others by volunteering. The following case
study describes The Mission Continues and its impact on participants:
Gould, O., Scheinberg, A., & Mathieu, M. (2014, November). The Mission Continues: A case study of the Well After
Service model. Washington, DC: Center for a New American Security. Retrieved from http://www.cnas.org/the-
mission-continues#.VnskL08erSg
Mojo Programme (Ireland)
http://www.mojo.ngo/
Mojo is a 12-week training program for men ages 20 and over who are having difculty coping with unemployment
or nancial difculties. Its stated goal is to reduce the high levels of male suicide in Ireland. Mojo seeks to increase
men’s resilience and mental and physical tness and develop their ability to engage with local services, set goals,
and develop a life plan. Mojo has produced a toolkit to help others start Mojo programs and is working to imple-
ment more programs across Ireland. For more information on the impact of its activities, see the following:
Burtenshaw Kenny Associates. (2013, December). Mojo nal evaluation report: Men at risk to suicide: An inter-agency
response. Retrieved from http://www.mojo.ngo/?project=mojo-nal-evaluation-report-men-at-risk-to-suicide-an-
interagency-response
Mojo: A 12 week programme for unemployed men experiencing mental health distress, a social return on investment
analysis 2014. Retrieved from http://www.mojo.ngo/?project=extended-wide-project
National Suicide Prevention Lifeline (USA)
http://www.suicidepreventionlifeline.org/
The National Suicide Prevention Lifeline is a 24-hour, toll-free, condential suicide prevention hotline available to
anyone in suicidal crisis or emotional distress. Calls to 1-800-273-TALK (8255) are routed to the nearest crisis
center in a national network of more than 160 centers that provide crisis counseling and mental health referrals.
The Lifeline is also available by online chat. For information on the impact of the Lifeline, see the following:
Gould, M. S., Munfakh, J. L., Kleinman, M., & Lake, A. M. (2012). National suicide prevention lifeline: Enhancing
mental health care for suicidal individuals and other people in crisis. Suicide and Life-Threatening Behavior, 42(1),
22–35. Retrieved from https://msrc.fsu.edu/system/les/Gould%20et%20al%202012%20National%20suicide%20
prevention%20lifeline--%20enhancing%20mental%20health%20care%20for%20suicidal%20individuals%20and%2-
0other%20people%20in%20crisis.pdf
Gould, M. S., Kalafat, J., Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2:
Suicidal callers. Suicide and Life-Threatening Behavior, 37(3), 338–352. Retrieved from http://onlinelibrary.wiley.com/
doi/10.1521/suli.2007.37.3.338/abstract
Kalafat, J., Gould, M. S., Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1:
Nonsuicidal crisis callers. Suicide and Life-Threatening Behavior, 37(3), 322–337. Retrieved from http://onlinelibrary.
wiley.com/doi/10.1521/suli.2007.37.3.322/abstract
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Oz Help Foundation (Australia)
https://ozhelp.org.au/
Oz Help seeks to prevent suicide among men by providing services at workplaces, including counseling, health
checks, suicide prevention and mental health awareness trainings, and information sessions on other mental
health and health-related topics. Oz Help also provides support from professional counselors in response to
critical incidents that affect the workplace.
Real Warriors Campaign (USA)
http://www.realwarriors.net/
This multimedia public awareness campaign is designed to combat stigma, encourage help seeking, promote
resilience, facilitate recovery, and support reintegration among returning service members, veterans, and
their families. It is part of the U.S. Department of Defense’s effort to encourage warriors and families to seek
appropriate care and support for mental health concerns. It uses a variety of strategies, including outreach and
partnerships, print materials, media outreach, an interactive website, a mobile website, social media, and stories
of service members who reached out for support or mental health care with successful outcomes. For more
background on this effort, see the following report:
Acosta, J., Martin, L. T., Fisher, M. P., Harris, R., & Weinick, R. M. (2012). Assessment of the content, design, and
dissemination of the Real Warriors Campaign. Santa Monica, CA: RAND Corporation. Retrieved from http://www.rand.
org/pubs/technical_reports/TR1176.html
The Role of Adult Correctional Ofcers in Preventing Suicide (USA)
http://www.sprc.org/sites/default/les/resource-program/CorrectionOfcers.pdf
This short publication provides basic information to help correctional ofcers in facilities for adults recognize
and respond to people who may be suicidal or at high risk. It includes a link to a list of resources on suicide
prevention in adult correctional facilities.
Safety Planning Guide: A Quick Guide for Clinicians (USA)
http://www.sprc.org/sites/sprc.org/les/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf
A safety plan is a personalized list of coping strategies and sources of support that can be used by people at
high risk for suicide in health or behavioral health care settings. This two-page guide for clinicians describes the
steps for helping patients create a safety plan. It can be used in conjunction with the Patient Safety Plan Tem-
plate (http://www.sprc.org/library_resources/items/patient-safety-plan-template), a ll-in-the-blanks guide to
developing a safety plan.
SBIRT: Screening, Brief Intervention, and Referral to Treatment (USA)
http://www.integration.samhsa.gov/clinical-practice/SBIRT
SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and depen-
dence on alcohol and illicit drugs. More information can be found in the following article:
Agerwala, S. M., & McCance-Katz, E. F. (2012). Integrating screening, brief intervention and referral to treatment
(SBIRT) into clinical practice settings: A brief review. Journal of Psychoactive Drugs, 44(4), 307–317. Retrieved from
http://www.tandfonline.com/doi/abs/10.1080/02791072.2012.720169?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.
org&rfr_dat=cr_pub%3dpubmed
Sequential Intercept Model (SIM) (USA)
http://www.prainc.com/wp-content/uploads/2015/10/SIMBrochure.pdf
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SIM provides a conceptual framework for communities to organize strategies for individuals with behavioral
health disorders who are involved in the criminal justice system. It identies “intercept points”—opportunities for
linkage to services and prevention of further penetration into the criminal justice system. It can help states and
communities assess available resources, determine gaps in services, and plan for change in the community.
Soften the Fck Up (Australia)
http://softenthefckup.spurprojects.org/
This media campaign for young Australian men encourages them to get help for their problems. The website
features several videos, a “Boot Camp” for men looking for resources, and “The Cafe,” a place where men can
help other men.
Suicide Action Montreal (Canada)
http://suicideactionmontreal.org/index.php?page=home
In addition to their 24/7 crisis phone line, Suicide Action Montreal provides services for the friends and families
of at-risk men that are designed to increase the suicidal man’s social supports and connectedness and to min-
imize barriers to help seeking. The services include face-to-face information sessions, rapid referral, and tele-
phone support. The following article provides more information about the impact of these services on the friends
and family of men and on the men’s risk factors:
Mishara, B. L., House, J., & Lavoie, B. (2005). Comparison of the effects of four suicide prevention programs for family
and friends of high-risk suicidal men who do not seek help themselves. Suicide and Life-Threatening Behavior, 35(3),
329–342. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16156493
Suicide Prevention: A Role for Firearm Dealers and Ranges (USA)
http://theconnectprogram.org/rearms-safety-coalitions-role-nh-suicide-prevention
This project from the New Hampshire Firearms Safety Coalition engages gun shop and ring range owners, their
employees, and their customers in understanding and taking action to prevent suicides associated with rearms.
The website offers materials to support this effort. Similar programs are being implemented in other states, includ-
ing Colorado, Maryland, Tennessee, Nevada, and Vermont. More information can be found in this article:
Vriniotis, M., Barber, C., Frank, E., Demicco, R., & the N.H. Firearm Safety Coalition. A suicide prevention campaign
for rearm dealers in New Hampshire. Suicide and Life-Threatening Behavior, 45(2), 157–163. Retrieved from http://
onlinelibrary.wiley.com/doi/10.1111/sltb.12123/abstract
TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (USA)
ñ Manual: http://store.samhsa.gov/product/TIP-50-Addressing-Suicidal-Thoughts-and-Behaviors-in-Sub-
stance-Abuse-Treatment/SMA15-4381
This manual provides guidelines to help substance abuse treatment counselors work with adults who have sui-
cidal thoughts and behaviors. It covers risk factors and warning signs for suicide, core counselor competencies,
clinical vignettes, and information for administrators and clinical supervisors. The accompanying Quick Guides
for clinicians and for administrators summarize the information in TIP 50 in easily accessible, “how-to” formats.
ñ Training DVD (updated version): Available free of charge from Jane Wood at Jane.W[email protected].
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This updated version of the 75-minute Web-based training introduces and models the concepts in the TIP 50
manual, including how to assess for suicidal thoughts and behaviors and develop treatment plans for people
who have a substance use disorder. It features demonstration conversations between therapists and clients,
including an additional case example. This DVD was developed for treating veterans but can also be used with
other populations. An evaluation of the original version of the training can be found here:
Conner, K. R., Wood, J., Pisani, A. R., & Kemp, J. (2013). Evaluation of a suicide prevention training curriculum for
substance abuse treatment providers based on Treatment Improvement Protocol Number 50. Journal of Substance
Abuse Treatment, 44(1), 13–16. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640862
TIP 56: Addressing the Specic Behavioral Health Needs of Men (USA)
http://store.samhsa.gov/product/TIP-56-Addressing-the-Specic-Behavioral-Health-Needs-of-Men/SMA14-
4736
This manual addresses the treatment needs of adult men with substance use disorders. It reviews gender-
specic research and practices, such as common patterns of substance use initiation among men, issues
specic to counseling men, and different types of treatment. It also addresses the needs of specic populations
of men in behavioral health settings. The accompanying Quick Guide summarizes the information in TIP 56 in an
easily accessible, “how-to” format for clinicians.
Together for Life (Canada)
For information on this program, contact Normand Martin at [email protected].
This suicide prevention program targets police ofcers and involves an awareness campaign; training for all
ofcers, supervisors, and union reps; and a peer police support phone line. The goal is to increase the capacity
of the police force to support one another in seeking help and preventing suicide. The program was developed
in Montreal and is currently being implemented in New Brunswick. The program led to a signicant decrease in
suicide rates among police in Montreal. Information on a study of Together for Life is available here:
Mishara, B. L., & Martin, N. (2012). Effect of a comprehensive police suicide prevention program. Crisis, 33(3), 162–
168. Retrieved from http://econtent.hogrefe.com/doi/pdf/10.1027/0227-5910/a000125
Value Options: Strategy in Workplace Suicide Prevention (USA)
http://valueoptions.com/clients/Initiatives/suicide_prev/html%20pages/Strategy.htm
This website includes information and resources that can be used to create a workplace suicide prevention
program. The resources include materials for senior management, articles, tip sheets, self-scored quizzes, and a
suggested timeline for covering different topics.
Veterans Crisis Line (USA)
https://www.veteranscrisisline.net/
This program connects veterans in crisis and their families and friends with responders at the U.S. Department
of Veterans Affairs through a condential toll-free hotline, online chat, and text. With the caller’s permission,
responders can view computerized patient records of each caller. Suicide prevention coordinators contact call-
ers within 24 hours of the generation of a consult and, when appropriate, assess the callers risk and needs to
provide referrals to appropriate local services. The following article provides more information:
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Britton, P. C., Bossearte, R. M., Thompson, C., Kemp, J., & Conner, K. (2013). Inuences on call outcomes among
veteran callers to the National Veterans Crisis Line. Suicide and Life-Threatening Behavior, 43(5), 494–502. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/23611446
Working Minds (USA)
http://www.workingminds.org
Working Minds provides tools, networks, training, social marketing campaigns, and consultation to assist
workplaces in implementing a comprehensive approach to suicide prevention, intervention, and postvention.
Although this program can be used in any workplace, Working Minds currently focuses on workplaces that
primarily employ men, including rst responders (law enforcement, reghters, and EMS) and the construction,
oil, and gas industries.
Your Voice Counts Resource Center (USA)
http://resource-center.yourvoicecounts.org/
California’s “Know the Signs” suicide prevention social marketing campaign teaches people to recognize the
warnings signs for suicide, offer help, and reach out to local resources. The following compaign materials,
housed at the Your Voice Counts Resource Center, target MIMY in particular:
ñ Print ads:
http://resource-center.yourvoicecounts.org/content/suicide-prevention-print-ad-bowling-behind-closed-
doors
http://resource-center.yourvoicecounts.org/content/suicide-prevention-print-ad-bbq-surrounded-friends
ñ Radio spot:
http://resource-center.yourvoicecounts.org/content/english-radio
For permission to use these materials outside of California, contact Theresa Ly at Theresa.L[email protected].
Zero Suicide (USA)
http://zerosuicide.sprc.org/
The Zero Suicide approach seeks to improve care and outcomes for individuals at risk of suicide in health and
behavioral health care systems. It prescribes a specic set of strategies and tools for implementing training,
screening, assessment, treatment, care transitions, and data collection.
ACKNOWLEDGEMENTS
2016
Suicide Prevention Resource Center
Web: www.sprc.org E-mail: [email protected] Phone: 877-GET-SPRC (438-7772)