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Five years ago, Josh was standing on a bridge, texting his brother a good-bye message. He had been severely depressed for months, and the counselling that he was receiving and medication he was on wasn't helping much. "I had lost all sight of ever getting better, and of anything enjoyable I'd ever done," he says.

He jumped.

But he didn't die.

Despite breaking six ribs and puncturing a lung, he woke up in the water. Adrenaline and instinct led him to swim to a nearby platform, where he was soon picked up by emergency services - his brother had received his text and called 911.

Today, Josh is doing much better. But he wonders what would have happened if he'd reached out for help earlier, before his depression worsened. "I basically never talked about my emotions with anybody; I felt like I wanted to figure things out on my own," he says. "It was only when I was obviously really sick and ill that I reached out, because I couldn't pretend anymore."

He now works for HeadsUpGuys, a website based out of the University of British Columbia that focuses on men and mental illness. The experience has changed his perspective on why he didn't feel comfortable asking for professional help earlier.

"Before, I never even thought of mental health in terms of what it means to be a man. [Through my work I realized] that I probably never asked for help because of those male stereotypes," he says. "We have 11 story videos and a whole bunch of blogs on the site, and basically every time it's they didn't talk about their emotions with anybody, they wanted to figure it out on their own. You hear the same story [over and over again], and it's my story too."

Suicide is often thought of as a gender-neutral issue, but in reality, it's a problem that affects men far more than women. Three times as many Canadian men kill themselves every year than women do - in Ontario, that means more men are dying from suicide than from car accidents.

That's why many argue that suicide prevention programs should recognize that men are a high risk group and tailor messaging and programming to them. That's starting to happen, with websites like HeadsUpMen and groups like Men's Sheds, which offer a space and tools where men can gather to work on projects and make connections. Many of these are partially funded by the Movember Foundation, a men's health organization, which has highlighted male suicide as one of its key areas of investment.

Deadly choices

Women are actually more likely to try to kill themselves - three to four times more likely. But men are more likely to die from it. That's a pattern that holds true across Canada, and in most of the rest of the world as well.

That's mainly due to two things: "One is that men use more lethal means [to attempt suicide], and the second is that they don't seek care as much," says Simon Hatcher, vice-chair of research for the Department of Psychiatry at the University of Ottawa.

Men are more likely to use firearms and other deadly methods, while women are more likely to use pills. These differences might be because men are more comfortable with guns. Or it might be that, as some researchers have suggested, they're choosing more extreme methods because they're more suicidal in the first place.

Is masculinity getting in the way of getting help?

Having mental health issues is a major predictor for suicide - almost everyone who dies from suicide has an underlying mental health problem. "Ninety percent of people who die by suicide are experiencing some sort of mental illness or addiction, most often depression," says Ed Mantler, vice president of programs and priorities at the Mental Health Commission of Canada. But not everyone with mental illness kills themselves. So what distinguishes those who do from those who don't?

One thing is a strong support system. There's evidence that men who adhere more strongly to masculine ideals see getting psychological help more negatively. That can result in their feelings building up without an escape valve - either a personal one, through talking with friends and family, or a professional one, through therapy or other mental health services - and can escalate to a crisis point. Studies show that in the year before they killed themselves, only 35 percent of men saw a mental-health practitioner, while 58 percent of women did.

"If a guy says, well my sense of being a man means that I can't disclose any vulnerabilities, because that will make me look weak, if something [like depression] does come up, what do I do with that? I have to keep it to myself," says John Oliffe, founder and lead investigator of the Men's Health Research program at UBC.

He also questions the commonly held belief that women are more likely to suffer from mental illness than men are. "Historically these numbers have been bandied about - that women have twice the rate of depression, but men have higher rates of suicide," he says. "But when you look more into contemporary epidemiological research, the numbers start to look a little different."

That's especially true when you consider that men's symptoms of depression may be different than women's. Instead of crying more, for example, Oliffe's research has shown that increased anger, risk taking, irritability and substance abuse might be more common signs of depression in men. "Men will talk about not being able to sleep, about back pain, but they won't say they're feeling sad and incompetent," says Julie Campbell, executive director of the Canadian Association for Suicide Prevention.

They do, however, interact with their primary care providers: Most men who kill themselves have seen their family doctor within the month. A new online course, certified by the College of Family Physicians of Canada, hopes to better educate family physicians about signs of suicide and depression in both men and women.

"Quite often we hear from family physicians that they're reluctant to even ask questions [about mental health]. If your doctor doesn't ask the question, it's unlikely that most of us would volunteer that information," says Mantler. "So providing physicians with the knowledge to have that conversation is important."

Vulnerable groups

Some sub-groups of men are also more vulnerable to suicide: gay and transgender men, Indigenous men and those vulnerable to Post-Traumatic Stress Disorder, such as first responders and soldiers. Men who are in a lower socioeconomic class are also more likely to try to kill themselves.

Early life experiences also play a role: Having parents who separated early in their lives and a family history of suicide are much more predictive of men dying from suicide than they are for women.

And age is a factor. While suicide is often thought of as a young person's problem, across Canada, Britain and the U.S., the group most likely to kill themselves are actually middle aged men. Nine of every 100,000 men 15 to 19 died of suicide, while 28 of every 100,000 who are 45 to 54 did. (The rate for women 45 to 54 is only 8.5 of 100,000.)

"It's a bit of a myth that the most prevalent group is young people," says Robert Whitley, Principal Investigator of the Social Psychiatry Research and Interest Group at McGill's Douglas Hospital Research Center. "If you zero in on why it's so high in the 40 to 60 age group, one of the key theories is that that's an age where many men become unemployed or divorced."

Job losses increase the risk of suicide two- or three-fold, and men who are single, widowed or divorced are more likely to kill themselves. Relationship breakdowns like divorce are more likely to lead men to suicide than women, possibly because women tend to have close same-sex friendships throughout their lives, while men's same-sex friendships fade after 30.

"What's common is that many people felt they had a sense of predictability, meaning and purpose [in their jobs, marriages or role as a father.] There's a sense that the carpet is being pulled out from under their feet, and a sense of alienation. Suddenly they feel completely rejected and misunderstood," says Whitley

Solutions to prevent suicides

The big picture answer to this problem, says Oliffe, is addressing the issue of masculinity in our culture. "I really do think our society and culture needs to take collective responsibility in redefining what it means to be a man," he says. He's hopeful that the image of men needing to be "the sturdy oak" is diminishing in younger generations.

Campbell agrees - and says those shifts need to be embraced by women, too. "Men need to learn to do things differently, but women are not that comfortable with these changes. We always say that men should be able to cry more, but it's any man but our man. We're still a bit stuck in those roles, and we need to work on each side."

Simply being aware of gender in our research and our approaches is another key step. "To ask, are there times where we need to have different approaches in men and women? Even that is very powerful," says Joy Johnson, vice-president of research at Simon Fraser and formerly the Scientific Director for the Institute of Gender and Health at the Canadian Institutes of Health Research. "We need to start to systematically think about an approach that could reach out to men and boys."

That might mean focusing on suicide prevention strategies like limiting access to firearms. Or it might be offering programming that's different than traditional face-to-face therapy.

Some examples exist from around the world: The U.S. Air Force successfully dropped suicide levels beginning in the 1990s by setting up 11 initiatives which normalize distress, encourage seeking help and educate leadership about warning signs of suicidality. After the program started, the mean suicide rate dropped from 3 per 100,000 to 2.4 per 100,000.

When Ireland had a spike in men's suicides, they adopted Australian's Men's Sheds initiative, where men gather to complete projects and chat, reducing isolation in older and unemployed men in particular. Canada has also recently started embracing men's sheds. (There is evidence that the sheds reduce isolation, though their direct effect on mental health is still unproven.)

Offering more mental health resources online and through apps might be one way to make those services more attractive to men. "Online approaches for most men work much better. We need to give them a mechanism to find out answers on their own before they're ready to seek help," says Johnson. "And there is a real bias towards cognitive behavioural therapy, because it's action oriented - you create plans, you do things. The nice thing about that is it can be offered online, too."

The number of websites tailored to men's mental health is growing. #SickNotWeak, which was created by sports journalist Michael Landsberg, encourages users to talk about mental illness. Kids Help Phone started a " BroTalk" portal in 2015, that's tailored to teenage men. And Head's Up Guys, which is based out of UBC and which Oliffe consulted on, has seen 350,000 visitors since it launched in 2015. He hopes its simple design and action-oriented terms - like "act early and decisively" or "get the upper hand on depression early" - will help men feel more comfortable.

"We have very purposeful language," says Oliffe. "We speak to guys directly, and use language that doesn't complicate their health and (doesn't) complicate what depression is." Some 40,000 visitors to the site have used its self-check section, which asks about symptoms of depression. Exact numbers aren't available yet, but many of the site's users reported feeling suicidal every day.

A similar site in the U.S., called Man Therapy, uses humour to make men more comfortable with talking. It highlights messages like "a moustache is no place to hide your emotions" and "sometimes a man just needs a pork shoulder to cry on," and features informative videos from "Dr. Rich Mahogany." The site includes personal stories from men who have overcome mental illness and a self-assessment tool for depression and anxiety - what it calls a "head inspection" - and directs people to self-help resources, crisis hotlines, and local therapists.

Within 18 months after launch, the site had had more than 350,000 visitors, nearly 60,000 of whom completed the "head inspection." Some 17 percent said the thing they liked most about the site was that it was manly. Fifty one percent of people who answered a pop-up survey on the site said they were more likely to seek help after visiting it. It was co-created by the Colorado Department of Public Health and Environment and a marketing company, and versions have since spread to other parts of the U.S. and to Australia. It has also been customized for first responders.

And of course, the last part of this is making sure that mental health resources are there for the men and women who do reach out by investing more in mental health, especially psychotherapy.

"People are always contacting me, like 'I need some help, but I can't pay,' and I'm handcuffed, there's no one to send them to," says Oliffe. "But the main problem is that men aren't coming through the door in the first place."

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Vanessa Milne, Joshua Tepper & Jeremy Petch

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The suicide gap: Why men are more likely to kill themselves

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Five years ago, Josh was standing on a bridge, texting his brother a good-bye message. He had been severely depressed for months, and the counselling that he was receiving and medication he was on wasn't helping much. "I had lost all sight of ever getting better, and of anything enjoyable I'd ever done," he says.

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Stereotyping makes guys have to hold in there emotions, guys can't really show emotions because that means they are weak and society stereotyped guys have to be strong and can not show sadness so guys hold in all their emotions that is why guys have higher suicide rate.

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Suicides have become the second-leading cause of death among teenagers in the United States, surpassing homicide deaths, which dropped to third on the list (see Figure 1). The teenage suicide rate increased from 8 deaths per 100,000 in 1999 to 8.7 deaths per 100,000 in 2014.

Higher suicide rates are driven in part by changes in the method of suicide. Suffocation, which includes hanging and strangulation, and is highly lethal, increased as a method of suicide. A rising suicide rates among teenage girls is driving the higher overall suicide rate.

Despite the rise in suicide, the overall mortality rate among teenagers has fallen from 68.6 deaths per 100,000 in 1999 to 45.5 deaths per 100,000 in 2014, as a result of declining homicide and traffic accident death rates during the past 15 years. Data are based on Population Reference Bureau (PRB)'s analysis of mortality statistics from the U.S. Centers for Disease Control and Prevention (CDC).
Figure 1

Lethal Methods Contribute to Rising Suicide Rate

A higher rate of suicide attempts does not appear to be driving the increasing teenage suicide rate. Data from the Youth Risk Behavior Surveillance System show that among high school students, the prevalence of attempting suicide remained flat from 1999 to 2013. ¹ Rather, suicide attempts today appear more likely to result in death because teenagers have shifted to more lethal methods of self-harm-a trend that has alarming implications. ²

The frequency of suffocation (a particularly lethal form of self-harm, which includes hanging) as the reported cause of suicide-related death among teenagers nearly doubled over the past 15 years. The share of teenage suicides due to suffocation rose from more than one-quarter (27 percent) in 1999 to nearly one-half (45 percent) in 2014.

Both teenage boys and teenage girls are increasingly likely to commit suicide by suffocation. From 1999 to 2014, the overall suicide rate among teenage girls increased by 1.5 deaths per 100,000, while the suffocation-related suicide rate increased by 1.4 deaths per 100,000 (see Figure 2). In other words, the increased rate of suffocation deaths accounted for virtually all of the increase in the suicide rate among teenage girls.
Figure 2

Among teenage boys, the suicide rate by suffocation increased by almost 60 percent across this period, but their overall suicide rate remained stable at 13 deaths per 100,000 due to a drop in the rate of suicide by other methods including firearms.

Increasing use of highly lethal methods of self-harm presents a significant public health challenge. The reasons teenagers are using more lethal methods to attempt suicide remain unclear. Some researchers hypothesize that social contagion-more exposure to suicide could induce at-risk individuals to attempt suicide-may be to blame, but there are no definitive answers. More research is needed to understand the underlying factors behind this trend. In the meantime, suicide prevention programs should continue working to address root causes, while also recognizing that the risk of death from a suicide attempt is rising.

Teenage Suicide Rates Rose for Nearly Every Demographic Group

The suicide rate for teenage boys was three times the rate for teenage girls in 2014. However, the rise in the overall teenage suicide rate between 1999 and 2014 was driven by the 56 percent increase in the suicide rate among teen girls-from 2.7 deaths per 100,000 to 4.2 deaths per 100,000.

Suicide rates rose for girls in every racial/ethnic category between 1999-2001 and 2012-2014. ³ Rates rose fastest for American Indian and Alaska Native girls (60 percent increase), and rates rose by more than 50 percent for both non-Hispanic Black/African American and non-Hispanic white teenage girls.

Among boys, only non-Hispanic Black/African American teenagers had lower suicide rates in 2012-2014 than in 1999-2001. As with girls, rates rose fastest for American Indian and Alaska Native teenage boys, and rates also increased for non-Hispanic white boys. Rates remained stable for Asian/Pacific Islander and Hispanic teenage boys.

Overall, the highest teenage suicide rates are among American Indian and Alaska Native teenagers. This may be partially explained by their greater concentrations in rural areas, where the risk of suicide is much greater (see map). Yet, even in rural areas, American Indian and Alaska Native teenagers have extraordinarily high rates of suicide, especially as compared with other racial/ethnic groups living in those areas.

Teenage Suicides Highest in Rural Areas

Suicide rates are higher in rural areas for a variety of reasons including social isolation, prevalence of firearms, economic hardship, and limited access to mental health and emergency health care services.

The teenage suicide rate in rural areas is nearly double the rate in highly urbanized areas (11.9 deaths per 100,000 in rural areas and 6.5 deaths per 100,000 in the most urban counties). ⁴ All of the states with the highest rates of teenage suicide-Alaska, South Dakota, Wyoming, and North Dakota-have relatively high proportions living in rural areas (see map). Conversely, the four states with the lowest teenage suicide rates-California, Connecticut, New Jersey, and New York-have predominantly urban and suburban populations.

In addition to having lower teenage suicide rates overall, the most urbanized areas saw no increase in suicide rates between 1999-2001 and 2012-2014. Rates rose in less urbanized areas and rural areas.

Looking Ahead

The recent decline in the overall teenage death rate shows that the United States is making progress in keeping children safe from harm. Yet the rise in suicide rates represents a significant and growing public health threat, and requires action. Suicide prevention strategies include depression/suicide awareness programs, expanded access to mental health services, and programs that support vulnerable populations (such as Native American teenagers, teenagers struggling with gender and sexual identity, and those with mental health or substance abuse problems).

These troubling trends should serve as a reminder to health practitioners, hotline workers, and the public that teenage suicide risk should be taken seriously. Expanding mental health and other social and strengthening social connections with at-risk teenagers can help prevent these deaths. ⁵

References

1. Centers for Disease Control and Prevention (CDC), "Trends in the Prevalence of Suicide-Related Behavior National Youth Risk Behavior Survey: 1991-2013," accessed at www.cdc.gov/healthyyouth/yrbs/pdf/trends/us_suicide_trend_yrbs.pdf, on May 27, 2016; and Child Trends, "Suicidal Teens: Indicators on Children and Youth," (August 2014), accessed at www.childtrends.org/wp-content/uploads/2012/07/34_Suicidal_Teens.pdf, on May 27, 2016.

2. Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report, "Suicide Trends Among Persons Aged 10-24 Years, United States, 1994-2012," (March 2015), accessed at www.cdc.gov/mmwr/pdf/wk/mm6408.pdf, on May 27, 2016.

3. We use three-year rates for race/ethnic and state detail to improve the stability of rate estimates over time.

4. Highly urbanized areas are defined here as "Large Central Metropolitan" counties, and rural areas are defined as "NonCore (non-metro)" counties, based on the 2013 National Center for Health Statistics "Urban-Rural Classification Scheme for Counties." For more information, see www.cdc.gov/nchs/data_access/urban_rural.htm#update.

5. Substance Abuse and Mental Health Services Administration, "Suicide Prevention," accessed at www.samhsa.gov/suicide-prevention, on May 27, 2016.

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Suicide Replaces Homicide as Second-Leading Cause of Death Among U.S. Teenagers

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Suicides have become the second-leading cause of death among teenagers in the United States, surpassing homicide deaths, which dropped to third on the list (see Figure 1). The teenage suicide rate increased from 8 deaths per 100,000 in 1999 to 8.7 deaths per 100,000 in 2014.

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Suicide is a very serious as it is the second leading death in the United States of America. Suicide is when a person kills themselves. The reason why holding sadness in is bad is because it will make people think that they have nothing to live for or have nothing to do and might try to commit suicide.

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Depression is a mental illness affects daily routines, the way how it affects the persons daily routine differentiates between each person, and how much the depression affects them also vary.

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When someone is holding in their sadness and does not let anybody know they get depressed because their is no one to comfort them