Written submission from the Samaritans (MHM0057)

Samaritans is the UK and Ireland’s largest suicide prevention charity, taking 5.4 million calls for help a year – that’s someone contacting us every six seconds. We have 201 branches, with over 20,000 trained volunteers. We work in a wide range of community settings, including prisons, schools, workplaces, railways and hospitals. Given middle-aged men are at the highest risk of suicide in the UK, we welcome the opportunity to respond to this inquiry and set out our urgent recommendations for change. 

Summary of key points

• Someone takes their own life every 90 minutes, with nearly 6,000 lives lost in the UK every year.[1] The effects of these suicides are devastating, felt across the wider community, by family, friends, colleagues and witnesses, often shattering lives.
• Middle-aged men, particularly those on low incomes, remain at the highest risk of suicide in the UK.
• Suicide is not only a gender inequality issue, but an economic inequality issue – deprivation and financial insecurity are strongly associated to an increased risk of suicide in men.
• Good progress has been made to help prevent suicides amongst men: they are a priority group in the national suicide prevention strategy and in national guidance for local authorities, and nearly every local area in the UK now has a suicide prevention plan in place.
• Additionally, £25 million has been allocated by NHS England for suicide prevention in the most high-risk areas and much of this money is going on actions targeted towards men.
• While this progress is welcome, there is still a long way to go, particularly to reach the men who are the most at risk and the least engaged with formal services.
• We know suicide is complex and there is rarely just one reason why someone takes their own life and service responses need to recognise this.
• We know that men are less likely to seek help and so we must look at more innovative ways of targeting men, especially middle-aged men to address the barriers that prevent them from seeking help.

Our recommendations

Our response sets out these recommendations in further detail. To improve efforts to prevent male suicide, Government should:

• Ensure national suicide prevention strategies and funding is targeting men at the highest risk, and that ambitious targets are put in place to measure this.
• Ensure and support local suicide prevention partnerships to prioritise robust and evidence-based interventions that target at-risk men.
• Support GPs to identify and respond to men who are in emotional distress, to improve access to timely, appropriate support.
• Ensure person-centred, holistic support is provided with joined-up services to address the multiple issues often faced by men who are suicidal.
• Increase and target funding to local alcohol and drug services, to make sure more men who may be in emotional distress and misusing substances get the support they need.
• Integrate loneliness and suicide prevention policy and ensure tackling loneliness in middle-aged men is prioritised, to help support men to improve their social support and networks.
• Embed suicide prevention within inequality and welfare policy, to improve the number of men on the lowest incomes and experiencing financial insecurity get the help they need.

Inquiry questions

1. What are the most pressing issues that affect men and boys’ mental health, and how are these different to the wider population?

Suicide is preventable and there is rarely one reason behind it. We know that only around a third of people who die by suicide have been under specialist mental health services in the year before they die[2], meaning that two-thirds have not been. Although mental illness, particularly depression,[3] is an underlying factor in most suicides, the majority of people with mental illness do not take their own lives.[4] Men, in particular, are less likely to seek help and reach out to formal services.[5] Understanding and preventing suicide amongst men and boys, therefore, demands a public health approach that is rooted in an understanding of suicide and socio-economic risk factors.

Male suicide is at its lowest in more than 30 years and while this reduction is very welcome, early indications for 2018 are that it is unlikely to be sustained for all age groups and men are still three times more likely to die by suicide than women.[6] The highest rate of suicide is among men aged 45-49 and it is a leading cause of death in young men.[7],[8]

Our response to this inquiry is taken from two major pieces of Samaritans’ research: Dying from Inequality (2016) and Men and Suicide: Why it’s a social issue (2012), which is focused on men in midlife from disadvantaged backgrounds. Our research found that the following priority issues disproportionately impact men’s suicide risk compared to the wider population:

i)                    Economic deprivation and inequality

• Men in the lowest social class, living in the most deprived areas, are up to ten times more at risk of suicide than those in the highest social class, living in the most affluent areas.[9]
• A 2019 Samaritans’ survey found that financial worries were the most commonly cited reason that men have felt low or found life tough in the past (36% of men in England, Scotland and Wales aged 20-59). Those on lower incomes were significantly more likely to say this than those on higher incomes. [10]
• The relationship between deprivation and increased suicide risk is complex and the result of numerous individual, societal and community factors interplaying in a person’s life. For instance, poorer areas, where there is typically a concentration of social rented housing, attract a higher proportion of people with pre-existing vulnerabilities (e.g. mental health problems) than more affluent neighbourhoods. These factors could in turn contribute to increased suicide risk.
• The link between deprivation and suicide is particularly pertinent given OECD figures suggest that the UK has among the highest levels of income inequality in the European Union,[11] and a recent study from the Resolution Foundation predicts this is unlikely to change. In fact, they found that for some aspects of inequality there are likely to be further challenges in the years to come, particularly for low income families. For instance, relative child poverty is projected to rise from 30% in 2016-17 to a record high of 37% in 2023-24.[12]

ii)                 Financial insecurity, changes to the labour market and recessions

• Suicide risk increases during periods of economic recession, particularly when recessions are associated with a steep rise in unemployment, and this risk remains high when crises end, especially for individuals whose economic circumstances do not improve. [13]
• Men are more vulnerable to the adverse effects of economic recession, including suicide risk, than women. During the 2008-09 recession, suicide rates in England and Wales rose significantly among men aged between 35–44, and those aged 45-64. [14]
• People who are unemployed are two to three times more likely to die by suicide than people in employment, and personal debt problems are associated with mental health problems and suicidal thoughts.[15]
• In a 2019 Samaritans’ survey 25% of men aged 20-59 cited job loss or job-related problems as a reason they’d felt low/found life tough in the past.[16]
• Unemployment in the UK is slightly higher among men than women,[17] and is also entwined with societal pressures and expectation on men that are elaborated on in this response. 
• Additionally, the changing nature of employment and the labour market over the last 60 years, with the shift to a service-economy, has particularly affected working class men, with the decline of traditionally male industries such as manufacturing. It is not simply having a job that is important to fulfil masculine identity, but also the type of job.[18]

iii)               Perceptions of masculinity

• Masculinity – the way men are brought up to behave and the roles, attributes and behaviours that society expects of them – contributes to suicide in men.
• In our 2019 survey with 3,000 men aged 20-59, 78% of men said it’s okay to admit you’re not feeling okay. Yet many still avoid speaking out when they’re finding life tough with two in five (41%) men in England, Scotland and Wales aged 20-59 saying they do not seek support when they need to, because they prefer to solve their own problems.[19]
• Masculinity is associated with control, but when men are depressed or in crisis, they can feel out of control. This can propel some men towards suicidal behaviour as a way of regaining control.[20]
• Suicide attempts may be interpreted by some men as shameful or even a ‘failure’, as it is related to the practice of self-harm, which is more often associated with women and therefore ‘femininity’. This may lead some men to use more extreme, violent methods.
• Stereotyping and expectations, including the pressure of being 'a real man' and being masculine, can also contribute to the following factors that may increase suicide risk: relationship breakdown, inability to talk about feelings, increased stigma around help-seeking, increased use of self-medication through alcohol and drugs, and increased risk of mental illness.
• Men are more likely to use substances to cope than to seek help from friends, family or formal services. For instance, men are less likely to access psychological therapies than women, only 36% of referrals to Increasing Access to Psychological Therapies (IAPT) are men.[21]
• The 2019 British Social Attitudes survey demonstrates the shift in views on gender roles over the last ten years; 72% of respondents disagreed with the view that,” a man’s job is to earn money; a woman’s job is to look after the home and family,” up from 58% in 2008. The survey found older people, people with no formal qualifications and people with lower incomes are more likely than other groups to hold traditional views on gender roles. [22]

2. What are the social and economic costs of poor mental health in men and boys?

Someone takes their own life every 90 minutes, with nearly 6000 lives lost in the UK every year.[23] The effects of these suicides are devastating, felt across the wider community, by family, friends, colleagues and witnesses, often shattering lives. The cost of a suicide has been estimated as £1.67 million with 70% of that figure representing the emotional impact on relatives.[24]

3. What is the effect of the following on men and boys’ mental health?

Suicide is complex, there is rarely one reason behind it. Men are not a homogenous group of people, in reality many of the individual, societal and environmental factors below interact to increase suicide risk, and in some cases shock life events and changes in circumstances can play a significant role.[25]

I)                   Gender stereotyping in childhood

• As outlined above, gender stereotypes around masculinity can play a significant role in increasing men’s suicide risk. 
• In particular, men tend to have less awareness and ability to cope with their own distressing emotions and those of others. In many cases this is a result of being taught through childhood, to be ‘manly’, which does not emphasise social and emotional skills – they learn to believe that struggling to cope constitutes a weakness.[26]
• Stereotypes embedded from childhood are often internalised and entrenched across men’s lives. Our research found that many middle-aged men raised in more traditional settings, struggle to align traditional stereotypes with the changing expectations, definitions and gender roles seen in society in more recent years.[27] 

ii)                 Gendered expectations around work

• Gendered expectations around work can contribute to suicide risk, including: the expectation of financial security, being the primary provider in a familial setting and male dominated work environments.
• These gendered work expectations can be particularly difficult to manage during times of unemployment. For instance, men may experience unemployment in mid-life as a double failure, since they are unable to meet two central demands of the masculine role: being employed; and ‘providing’ for the family. [28]  

iii)               Fatherhood

• Despite constantly changing discourses of fatherhood, many men, particularly working-class men, still consider providing for the family as most important, with the hands-on work of caring for children often still seen as non-masculine. [29]

iv)                Household finances

• There is a well-established link between suicide and poor socio-economic circumstances, as outlined above in our response.

v)                  Relationship and family breakdown

• Divorced men have more thoughts about suicide than divorced women and separated men are twice as likely as separated women to have planned suicide.[30]
• Men - particularly those in mid-life - are often overwhelmingly dependent on close familial relationships, primarily their romantic partner, for emotional support. Consequently, marriage breakdown is likely to lead to emotional distress and could increase suicide risk. [31]
• Marriage often entails more emotional distress for women than for men. Men may develop unrealistic, idealised expectations of relationships, while not having the emotional skills to negotiate the complex reality of relationships or cope with emotional distress, which may result in an intense, self-destructive reaction to relationship breakdown. [32]
• When marital relationships fail, men are less likely to be awarded custody of, or have access to, their children. Separation from children is a significant factor in some men’s suicides.[33] In addition, men are more likely to be displaced from the family home, to unstable accommodation or homelessness, itself a risk for suicide.[34]
• Middle-aged men are more likely to have low social support (practical, emotional or other types of help from family and friends) to help manage periods of family breakdown. Low social support and connections can could increase the likelihood of suicidal behaviour, whereas high social support can be a protective factor, particularly when individuals experience extreme stress. [35]

4. What issues other than access to healthcare affect the mental health of men and boys?

In addition to many of the socio-economic factors already mentioned in this response, the following issues can play a role: 

• Middle-age: problems with relationships and employment during mid-life are experienced intensely, because this stage of life is usually associated with stability and security.[36]  By their mid-years, people have typically invested a great deal in work and relationships. It is also a time when the possibilities for making changes in these areas, such as retraining and building a different career, are limited, and likely to come at a high cost. Men in mid-life can feel devastated when the choices they have made earlier in life appear to be ‘mistakes’.[37]
• Alcohol and drug use: men are more likely to ‘self-medicate’ with substances to manage their emotions and their (particularly depressive) symptoms and avoid ‘help-seeking’ (from both informal and formal sources). The risk of suicide when a person is currently abusing alcohol is eight times greater than if they were not abusing alcohol.[38]
• Negative experiences of loss (such as job loss and bereavement), adversity (including unemployment and unmanageable debt) or disadvantage (such as working in low-skilled, low status jobs) across an individual’s life increase the likelihood of self-harm or suicide.
• Adverse childhood experiences are known to increase suicide risk.[39] Men who have experienced difficulties in childhood and adolescence, or who have had years of mental health problems and alcohol misuse, may find their problems culminate in mid-life.[40]
• Personality traits: Samaritans’ research found six traits that can make people more vulnerable to suicide, including the desire to be perfect; self-criticism; brooding; and having no positive thoughts about the future. Suicide risk is especially high when these traits interact with other factors, such as deprivation, isolation and distressing life events. [41]

5. Which groups of men and boys are particularly at risk of poor mental health and what is leading to this?

As outlined above, men from low income groups, who are unemployed, in middle-age and who mis-use drugs and alcohol are at increased risk of suicide. In addition, data also suggest the following groups are at increased risk:

• Young male veterans: the overall rate of suicide is not higher for veterans than the general population, however, there is evidence that in male veterans aged less than 24, the rate is two-three times the national rate especially in those who have served a short period in the military, those of lower ranks and those who have attained lower educational achievement. Evidence also shows that many veterans who die by suicide often have pre-service vulnerabilities.[42]
• LGBT young people: evidence suggests individuals who are, or perceived to be, lesbian, gay, bisexual and transgender (LGBT) may be at increased risk of suicidal thoughts and behaviours.[43] A national inquiry of suicides amongst young people found that a quarter of LGBT young people under 20 who took their lives had been bullied and most had previously self-harmed.[44]
• Male prisoners: it is estimated that the likelihood of self-inflicted death is nearly nine times higher for people in prison compared to the general population.[45] Men make up around 95% of the prison population and between 2007 and 2017 the number of individual males self-harming, the strongest predictor of future suicide, has more than doubled while the number of individual women self-harming has decreased by almost a tenth (11%).[46]
• Low-skilled male labourers, particularly in construction, are three times more likely to take their own lives.[47] 

6. What measures are needed to most effectively tackle poor mental health in men and boys and what are the barriers that prevent these being implemented?

i)                    National suicide prevention strategies need to target men at the highest risk

Men are listed as a priority group in the national suicide prevention strategy and a lot of progress has been made in reducing their overall suicide risk. However, more needs to be done to reach men who are the highest risk and most likely to be disengaged with formal services. These interventions need to be developed in more innovative ways, given we know men are less likely to seek help and there are specific barriers that prevent them from seeking help. To do this government should:

• Put in place an ambitious national target to reduce male suicide, particularly those most at risk.
• Carry out an evaluation of the interventions that best support men and develop this into guidance for local authorities, to ensure that future funding for local areas is spent where it will have the most impact.
• Set out specific plans to tackle suicide as an inequality issue. Interventions and policy need to be designed to reach people on the lowest incomes, particularly middle-aged men. This should include working across communities using established channels to reach people, such as debt advisers and housing associations.
• Improve data collection and research into risk factors and high-risk groups. We have increasing knowledge of different high-risk groups, but more evidence is still needed to effectively prevent suicides. For instance, it’s becoming evident that gambling is linked to suicide, but much more needs to be known about it and how it may be linked to the high suicide rate amongst middle-aged men, as well as the ways that it interacts and combines with other risk factors.
• Ensure men with lived experience are at the centre of policy-making. The National Suicide Prevention Strategy Advisory Group should be consulting with a wider, diverse group of people with lived experience of suicidal behaviour and government should be supporting this national and local involvement with a safe, supported lived experience network.

ii)                 Local suicide prevention partnerships should prioritise interventions that target at-risk men

We know that men are less likely than women to seek help or talk about suicidal feelings and can be reluctant to engage with health and other support services. It’s therefore critical at a local level that everything is done to target and reach them. This is in line with PHE’s recommendations for local authorities. Local authorities should:

• Prioritise interventions that sek to reduce both gender inequality and economic inequality
• Work across local areas with agencies that are likely to encounter men at the highest risk, such as middle-aged men living with multiple risk factors like unmanageable debt, relationship breakdown or poor housing.
• Share intelligence and data across local areas and with national government, to better inform policy and practice.

iii)               Support GPs to identify and respond to distress in men

GPs are the most likely formal source of help to be consulted by men particularly those in middle-age, so it’s essential that they are able to identify men who might be in distress and provide support as needed. Government should:

• Ensure suicide prevention training is available for all primary care staff and embedded within health education. Such training should include recognition of emotional distress, depression and mental health problems, the most effective social and clinical support for men, as well as specific psychological and social risk factors for suicide.
• Evaluate the care pathway for men who are suicidal, to identify key areas for improvement and recommended solutions. In order to increase men’s access to formal support, but to also improve care planning, discharge and signposting.

iv)                Increase and target funding to local alcohol and drug services

The links between substance misuse, masculinity, deprivation and suicide have been clearly outlined in this response. Effective local substance misuse services, targeted to high risk groups, play a crucial role in preventing suicide. Despite this, specific budgets for the treatment and prevention of alcohol misuse have been cut nationally, including significant cuts for local areas that experience high levels of alcohol-related harm.[48] Government should:

• Use the upcoming Green Paper on Prevention and the Spending Review to set out a sustainable funding solution for suicide prevention and public health for the next ten years.
• Integrate substance misuse and suicide prevention policy and ensure there are cross-cutting targets and objectives across government. And that any changes to substance misuse provision take into account suicide risk for high risk groups and put in place mitigations to manage this.

v)                  Join up loneliness and suicide prevention policy

More integration is needed across loneliness and suicide prevention policy, given that loneliness and lack of social support can be significant issues that increase men’s suicide risk, particularly in middle-age. Government should:

• Put in place cross-cutting targets across loneliness and suicide prevention strategies, that seek to reduce loneliness amongst middle-aged men.
• Produce guidance for local authorities on the interventions that best mitigate loneliness, for men, particularly in middle-age.
• Provide training for local suicide prevention partnerships on loneliness and available funding streams.

vi)                Consider and embed suicide prevention within inequality and welfare policy

Active Labour Market Policies can help reduce suicidal behaviour. Programmes aimed at reintegrating unemployed people as quickly as possible into the labour market are likely to shorten the duration of unemployment and reduce social isolation by involving participants in training or education. They can also help people find employment which is a source of social contacts, status and self-esteem, thus reducing the risk of suicidal behaviour.[49] Government should:

• Ensure all benefit providers and frontline practitioners receive suicide prevention training and know how to support and signpost men who might be in distress.
• Ensure suicide risk is considered in impact assessments for changes to welfare and employment policies, and that mitigations are put in place to protect groups that are at the highest risk. The development of all welfare, housing and employment policies should include an evaluation of potential unintended impacts on mental health and suicidal behaviour.
• Invest in effective support for people who have experienced job loss and may be more vulnerable to suicidal behaviour.

7. How effective has Government policy been in improving mental health outcomes for men and boys?

Good progress has been made by Government in preventing suicide amongst middle-aged men, which can be seen in the reduction of the suicide rate. However, there is still a long way to go, particularly in reaching the middle-aged men in the most disadvantaged communities.

Despite national prioritisation of suicide prevention, we remain concerned that progress is being held back by delays across government, with no clear vision for how suicide rates are going to be reduced by 10% by 2020/21. In particular, it is still not clear how government plan to reach people who suicidal and are not engaged with health services, who are more likely to be men.

Suicide prevention is a cross-government priority and men are one of the priority groups in the national suicide prevention strategy. Our response outlines Samaritans’ view on the progress that has been made and the actions that are still needed across government departments, many of which are not included in the remit of this inquiry (e.g. the Department of Work and Pensions). More details about the government’s approach to suicide prevention can be found in its recently published workplan on suicide prevention and fourth progress report on the national strategy. [50]

8. How effective are the following at tackling poor mental health in men and boys:

i)                                                       NHS England

Good progress has been made towards the Government’s target to reduce suicide rates by 10% by 2020/21, which was set out in NHS England’s Five Year Forward View for Mental Health. NHS England has allocated £25 million to suicide prevention from 2018-2021. This additional funding is very welcome, however it’s not clear whether this funding stream will continue after 2021.

The NHS ten-year plan was also a missed opportunity. The plan contains some positive commitments on suicide prevention, but we were disappointed that it didn’t include an increased ambition for suicide prevention, such as a 10% further reduction in the suicide rate by 2028. We welcome the long-term investment in the NHS of over £20.5 billion over the next five years, which includes £2.3 billion for mental health.[51] But are concerned that it’s still unclear what proportion of this will reach suicide prevention.

i)                    Public Health England

Suicide is a major public health problem. Good progress has been made by Public Health England to help reduce suicide amongst men and boys in the last few years including: producing guidance for local areas on suicide prevention, working with Health Education England to produce a suicide prevention competency frameworks, working with NICE to produce guidelines on suicide prevention and self-harm and working closely with the Samaritans’ to ensure the safe reporting of suicide in the media. The guidance for local authorities specifically emphasises the importance of multi-agency suicide prevention partnerships targeting men.

ii)                 Child and Adolescent Mental Health Services

Effective clinical services play an important role in suicide prevention, however, this must also be supported by robust policy and interventions that seek to reduce the impact of underlying socio-economic risk factors. This is particularly important given a national inquiry of suicides in young people under 25 found that boys were less likely to have had contact with clinical services or agencies.[52] There is strong evidence showing that access to CAHMS needs improving across the board,[53] however this also needs to be joined up with a wider public health approaches to suicide prevention in young men and boys.

iii)               Local Authorities

The All-Party Parliamentary Group on Self-harm and Suicide Prevention report in 2015 is the most recent comprehensive overview of local authority activity to prevent suicide.[54] Since this report has been published, the majority of local authorities now have a suicide prevention plan in place. This a positive step in the right direction, but there has been little national evaluation of the effectiveness and implementation of these plans. It’s therefore difficult to ascertain how effectively they are reducing men’s risk of suicide. There is a real opportunity now for high quality national evaluation of the work funded by NHS England as well as a strong quality improvement programme to support local areas. It’s critical that suicide prevention funding reaches local areas, however we are concerned that the current approach is resulting in inefficiencies and duplication.

There are numerous examples of good public health interventions that are targeting men in local areas and much of the funding from NHS England has gone towards these interventions. For example, Warwickshire council’s ‘it takes balls to talk’ campaign, specifically seeks to target men and has linked a wide range of community-based organisation together to do this.[55] Our experience with local areas shows a willingness and commitment to work to prevent suicide within a context of reducing resources and competing priorities. However, much stronger national oversight is required to support local areas to implement and deliver local plans. In particular, national support should be directed towards local scrutiny boards to ensure they have the skills and expertise on suicide prevention to effectively scrutinise local plans.

iv)                Schools

Children and young people are a priority focus group in the national suicide prevention strategy and the Five Year Forward View for Mental Health – both strategies recognise the need to focus interventions on children who are the most at risk – such as looked after children, care leavers and those in the youth justice system.[56]  The suicide prevention strategy, NICE guidelines on suicide prevention[57] and PHE suicide prevention guidance for local authorities, all emphasise the important role schools need to play to deliver community-wide suicide prevention by linking up with their local multi-agency partnerships. [58]

PHE state that school based-awareness programmes have shown promise in reducing suicide attempts, [59] and that school-based programmes of social and emotional learning have the potential to help young people acquire the skills they need to make good academic progress as well as benefit pupil health and wellbeing.[60] Ultimately, training children and young people on emotional health, coping strategies, difficult feelings, asking for help and developing listening skills, is essential for reducing and preventing suicide.

We strongly welcome the commitments in the Government’s green paper on children and young people’s mental health – we are at a critical juncture to establish robust systems to protect children’s wellbeing both now and in the future. However, we strongly recommend that these guidelines and policies should be co-ordinated with the national suicide prevention strategy and local suicide prevention plans; NICE guidelines on suicide prevention and on self-harm; wider teacher training programmes and existing services in schools, such as DEAL, to maximise the impact for children and young people.

A whole school approach should be taken to embed mental and social wellbeing in schools and colleges. For instance, mental health training should be part of Initial Teacher Training (ITT) and continuous professional development as recommended by the Commission on Children and Young People’s Mental Health. The Department for Education and Health Education England should ensure the new curriculum guidelines, the upcoming review of the Ofsted Framework and further upcoming policies on children and young people’s mental health are co-ordinated with the national suicide prevention strategy and aligned with the aim to reduce deaths by suicide by 10% by 2021.

March 2019