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• To enhance your understanding of the factors that may contribute to suicide risk in men
• To recognise various ways in which crisis resolution and home treatment team practitioners can improve the care they provide to male service users and preserve their safety
• To identify how you can effectively assess suicidal ideation among men in your area of practice
Around three quarters of suicides in England and Wales in 2019 were among men. Crisis resolution and home treatment teams (CRHTTs) have been a focus of mental health policy in many countries since the late 1990s, and became embedded in the UK healthcare system in the 2000s. CRHTTs aim to avoid hospital admissions, where it is safe to do so, for service users experiencing an acute mental health crisis. However, it has been recognised that at present there are more suicides occurring in service users under the care of CRHTTs than those in inpatient settings. One reason for this may be because assessing suicide risk is often challenging for CRHTT practitioners.
This article identifies some of the factors that increase the risk of suicide in men, and provides recommendations for CRHTT practitioners on how to effectively assess suicidal ideation in male service users.
Mental Health Practice. doi: 10.7748/mhp.2021.e1568
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Citation Bell J, Fothergill A (2021) Identifying male-specific risk factors for suicide: a crisis resolution and home treatment team perspective. Mental Health Practice. doi: 10.7748/mhp.2021.e1568
Published online: 14 September 2021
In 2019, there were 5,691 suicides registered in England and Wales, with an age-standardised rate of 11.0 per 100,000 population (Office for National Statistics (ONS) 2020). Around three quarters of these suicides were among men, a trend that has been consistent since the mid-1990s, while the age-standardised suicide rate for men in 2019 was 16.9 per 100,000 – more than three times higher than the rate for women (ONS 2020).
There is a common belief that more men die by suicide than women because they choose more lethal methods, but Cibis et al (2012) found that even ‘low-risk’ methods are more lethal in men than in women. This suggests there are additional factors that may have led to the higher suicide rate in men.
Research has also identified concerns about the ability of crisis resolution and home treatment teams (CRHTTs) to manage suicide risk. For example, it has been estimated that in the UK there are more than twice the number of suicides in those under the care of CRHTTs compared with those in inpatient settings (Appleby et al 2019). Lamb et al (2020) concluded that knowledge of specific suicide risk factors – in this case for men – could enhance CRHTTs’ effectiveness in preventing suicide.
This article outlines factors that may contribute to the increased rates of suicide in men, and provides recommendations for CRHTT practitioners on assessing suicidal ideation in male service users.
• Around three quarters of suicides in England and Wales in 2019 were among men, a trend that has been consistent since the mid-1990s
• Since it is part of the remit of crisis resolution and home treatment teams (CRHTTs) to avoid hospital admissions where it is safe to do so, it is important for practitioners to understand the male-specific factors that increase suicide risk
• Factors that may contribute to suicide risk in men include masculine norms, lethality of the method of suicide, method substitution, alcohol use, stigma, relationship stress and adverse childhood experiences
• It is important that CRHTT practitioners engage in collaborative conversations with the service users they are assessing so that they can implement effective interventions that are compassionate, individualised and engaging, and therefore more likely to increase safety
CRHTTs aim to avoid hospital admissions, where it is safe to do so, for service users experiencing an acute mental health crisis, for example by assessing their risk of harming themselves or others (Lloyd-Evans et al 2018). The intention is for care to be delivered as close to home as possible, since it has been recognised that this increases service user satisfaction (National Audit Office 2007). In cases where hospital admission cannot be avoided due to a person’s level of risk, CRHTTs typically have a role in enabling early discharge by supporting people to return home from hospital as soon as it is deemed safe to do so (Clibbens et al 2018). CRHTTs are adaptable and their approach to team decision-making enables services users to have timely and rapid access to a range of healthcare professionals. Practitioners are able to operate in a more responsive way than traditional community mental health teams, which is facilitated by flexibility in terms of the length of time allocated to service user visits (Sjølie et al 2010).
Box 1 details the core components of CRHTTs. However, several issues have been identified in relation to these services. For example, one of the core components is for CRHTTs to operate 24 hours a day, but one UK survey of 75 CRHTTs found that only 40% did so (Lloyd-Evans and Johnson 2014). Research has found further differences in CRHTT provision across the UK, with teams often deviating from their intended role and remit, perhaps in response to local pressures or service differences (Rhodes and Giles 2014). An example of this is inconsistencies in the gatekeeping function of these services, potentially as a result of inter-team issues, whereby other healthcare teams are able to admit a person directly to hospital without requesting a CRHTT gatekeeping assessment. Lloyd-Evans et al (2018) found that there is low adherence to the core components of CRHTTs, with few teams adhering to implementation guidance.
• Provide a rapid, mobile response
• Undertake frequent visits, particularly during the early stages of a service user’s crisis
• Approach referrals to the CRHTT with the expectation that they will be managing the episode of care, to reduce the number of hospital admissions
• Address any practical issues, with the aim of enabling the service user to remain in the community
• Support optimal medicines management
• Remain involved until the crisis is resolved, and ensure handover to ongoing care, which is usually provided by the community mental health team
• Be available to respond to psychiatric emergencies 24 hours a day, seven days a week, 365 days a year
• Act as a gatekeeper to acute inpatient mental health services, rapidly assessing individuals with acute mental health issues and referring them to the appropriate service
• Involve the service user’s social support network at every phase of care
Morant et al (2017) conducted research to identify what service users believe comprises high-quality care from a CRHTT. They found that service users considered frequent home visits from the same staff and receiving emotional support to be important.
There is also evidence that a well-implemented CRHTT can be effective in supporting service users with their mental health. Murphy et al’s (2015) Cochrane review found some evidence – albeit of low or moderate quality – that compared with standard care, CRHTTs can reduce repeat admissions to hospital at six months, improve a person’s mental state and increase service user satisfaction. However, it should be noted that this Cochrane review only focused on people with a severe mental illness such as schizophrenia and did not measure the effectiveness of CRHTTs for people in crisis without a severe mental illness diagnosis, for example for a man referred to the service with suicidal ideation relating to social factors (Murphy et al 2015).
The implementation of CRHTTs in the UK in 2000, following the NHS Plan (Department of Health 2000), was initially thought to have had the most significant positive effect on suicide rates compared with other service developments in the UK (While et al 2012, Lloyd-Evans and Johnson 2014). However, the implementation of a 24-hour CRHTT is only one of several organisational factors that may affect suicide rates, and specific causal links between CRHTT and improved suicide rates have not been established (Kapur et al 2016). Little is known about what components of a CRHTT are most beneficial to men who are suicidal, and since the remit of these services is to avoid hospital admissions where it is safe to do so, it is important for CRHTT practitioners to understand the male-specific factors that increase suicide risk. This will enable them to decide on the appropriate interventions to support the male service users they assess in their practice.
It is important to be aware that the experience of suicidal thoughts is complex and dynamic, which makes it challenging for practitioners to predict adverse outcomes. For example, one report found that 85% of people with mental health issues who died by suicide in the UK between 2005 and 2015 were assessed on their last contact with services as having no or low immediate risk of suicide (Appleby et al 2017). This is perhaps unsurprising, given that it has been found that risk assessment tools do not accurately predict the likelihood of a person dying by suicide (Appleby et al 2018), and as such their use to predict risk of suicide is not recommended by National Institute for Health and Care Excellence (2011) guidelines.
This section is based on the findings of a literature review that one of the authors of this article (JB) conducted in 2017 to develop a comprehensive understanding of the factors that may contribute to suicide risk in men.
The literature review identified that there is a lack of evidence and no set format to support CRHTT practitioners in deciding how to undertake a crisis assessment. Furthermore, no literature was found that clarified how to assess risk at the point of crisis, in particular studies that would be useful to CRHTT practitioners when assessing men who are potentially suicidal. However, there was some evidence regarding the factors that contribute to the higher rates of suicide in men. It is important to note that although some of these factors can affect both men and women, the factors discussed in this section tend to be more relevant for men. Considering these factors could assist CRHTT practitioners to undertake effective suicide risk assessments of male service users, thus enabling them to provide appropriate care and preserve their safety.
Masculine norms contribute towards the development of a man’s identity, affecting his view of how he is expected to behave, what his role is and how he should feel. Some of the masculine norms that have been associated with a higher risk of suicide include (Cleary 2012, Witte et al 2012):
• Stoicism – the denial, suppression and control of emotion. Men often feel the same levels of emotional distress as women, but they may actively choose to conceal it, which can lead to some men opting for suicide rather than seeking help.
• Sensation-seeking – the propensity towards engaging in behaviours that involve risk, including risk of death. It has been identified that this trait leads to a higher capability for suicide in men because they may have a ‘fearlessness’ about death.
Keohane and Richardson (2018) asserted that these norms can significantly increase male suicidal risk because they may reduce the likelihood of men seeking help. However, Granato et al (2015) found that it is not masculine norms themselves that increase the risk of suicide, but that men are socialised to adhere to norms that encourage them to engage in painful and provocative life events. They gave the example of a male football player being injured who has been socialised to respond in an aggressive and competitive manner. When habitual, this behaviour can increase the likelihood of men engaging in impulsive, aggressive and risky behaviours, resulting in a greater acquired capability for suicide (Granato et al 2015). Similarly, the belief that men are less likely to demonstrate help-seeking behaviour than women was challenged by River (2018), who found that men often refrain from seeking help if services frame their issues in terms of ‘mental illness’. This implies that, for men, the stigma associated with having a mental illness is often more powerful than the stigma associated with needing help.
There is a long-established belief that rates of suicide are higher in men than in women because they tend to use more lethal methods (Canetto and Sakinofsky 1998). However, the latest evidence indicates that the case fatality rate is higher in men than in women across all methods of suicide (Cibis et al 2012). Therefore, it is important for CRHTT practitioners not to assume that a man who is suicidal might be at lower risk of ending his life if he speaks about seemingly less lethal methods.
If one method of suicide is removed or becomes unavailable, men are more likely than women to substitute it for another method of suicide (Klieve et al 2009). This factor is particularly relevant for CRHTT practitioners when making decisions about whether a service user requires home treatment or hospital admission. For example, when supporting a suicidal service user at home, a common intervention by CRHTT practitioners is to remove obvious means of suicide from the person’s home to reduce their access to these. Thus, if a CRHTT practitioner decides that a man who is suicidal can be supported at home, and with their consent removes obvious means of suicide, they should remain aware of the greater potential for them to seek other means of suicide that have not been previously discussed or considered.
There is evidence to suggest that alcohol has a greater role in suicide among men than it does among women, both in terms of long-term dependency and its use at the point of suicide (Schiff et al 2015). This may be due to its effects in terms of increasing impulsivity, which is a trait often seen in men. It may be beneficial for CRHTT practitioners to regularly check male service users’ alcohol use during a period of home treatment care, and to review their risk of suicide if they report an increase in alcohol use.
Owens and Lambert (2012) interviewed family members of people who had died by suicide, identifying that in some cases male suicide is framed as a ‘heroic’ act by those who are bereaved, since they may perceive it as a ‘courageous and rational act of self-sacrifice’. However, equally, some bereaved family members described men who died by suicide as violent or ‘bad’. Owens and Lambert (2012) concluded that it was rare for men to be viewed as having died by suicide as a result of being ‘mentally ill’. A lack of understanding about men’s mental health can lead to stigma, which reinforces negative societal attitudes towards depression and suicide in men (Oliffe et al 2016). As a consequence, men may feel judged by society, which can adversely affect their feelings of self-worth, particularly if a man and his significant others aspire to the masculine norms detailed previously.
Relationship stress has been found to place men at greater risk of suicide than women (Lee and Pridmore 2014). Schiff et al (2015) found that issues relating to intimate partners were present in almost 60% of suicides by men. However, research by Tsai et al (2014) identified that men who are socially well-integrated are less likely to die by suicide than those who are not. Marital status, social network size and attending religious services were found to have the most significant effects on reducing the risk of suicide (Tsai et al 2014).
Adverse childhood experiences appear to have a greater correlation with suicide in later life for men than for women. For example, one study by Rajalin et al (2013) identified that men who have a family history of suicide and/or exposure to violence in childhood are more likely to be predisposed to suicide compared with women who have had these adverse childhood experiences. It also found that such men are increasingly likely to make serious and well-planned attempts to end their lives, thus further increasing their risk of dying by suicide.
Childhood sexual abuse has also been found to increase the risk of suicide in men (Easton et al 2013). When combined with violence and low levels of maternal support, this risk increases further (Easton and Renner 2013).
It is important for CRHTT practitioners to be aware of the male-specific risk factors described in this article and use them as the basis for a suicide risk assessment. In addition, it is important for practitioners to engage in collaborative conversations with the service users they are assessing so they can implement effective interventions that are compassionate, individualised and engaging (Cole-King et al 2013), and therefore more likely to increase safety.
Table 1 details some areas for CRHTT practitioners to consider when caring for men who are at risk of suicide.
CRHTT practitioners could benefit from attending training that not only raises their awareness of the male-specific factors that can increase suicide risk, but also provides them with the knowledge to develop personalised and meaningful safety plans with service users.
The use of risk assessment tools for predicting the likelihood of a person dying by suicide has been found to be ineffective and is not recommended by national guidelines. Therefore, a combination of clinical judgement, effective therapeutic relationships and collaborative planning is required to mitigate the risk of suicide. There are several male-specific factors which CRHTT practitioners can assess that may increase the likelihood of identifying men who are at risk of suicide. These factors can subsequently be incorporated into an individual risk mitigation plan that details appropriate interventions to preserve the safety of these service users. CRHTT practitioners also need to be aware that the language they use can affect male service users’ engagement with the service.
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