Original Research

Antecedents and service contact in an observational study of 242 suicide deaths in middle-aged men in England, Scotland and Wales, 2017

Abstract

Introduction Middle-aged men are the demographic group at highest risk of dying by suicide. We conducted a national study of deaths by suicide in men in mid-life to investigate the stresses they face before they take their lives and their contact with services that could be preventative.

Methods This study is a detailed descriptive examination of suicide in a sample of men aged 40–54 who died by suicide in England, Scotland and Wales in 2017, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, mainly coroner inquests and police death reports.

Results In 2017, there were 1516 suicides by middle-aged men, representing 25% of all suicide deaths. Of the 288 suicide deaths in middle-aged men randomly selected for review, we obtained data about antecedents on 242 (84%). Many were unmarried (161, 67%). We found a complex pattern of stresses and recent adversity before suicide including economic adversity (139, 57%), physical ill-health (125, 52%), self-harm (106, 44%), alcohol and/or drug misuse (119, 49%), and bereavement (82, 34%; including by suicide, 14, 6%). Most men (220, 91%) had known contact with healthcare, justice system or other support services—67% (n=162) in the previous 3 months, 38% (n=91) in the previous week. Contact with multiple agencies was reported for 17% of men.

Conclusions A mix of long-standing and recent risks contribute to suicide risk in men in mid-life. Economic stresses, including unemployment, financial and housing problems, are particularly important factors in this group. Contrary to our expectations, most men were in contact with support services. Economic support (especially at a time of severe economic pressure), addressing isolation, joint working with the voluntary sector, and addressing specific stresses, such as bereavement, may help reduce risk.

What is already known on this topic

  • In the UK, middle-aged men have the highest suicide rate, but there are few national studies examining the antecedents of suicide in this group.

What this study adds

  • We identified multiple stresses and recent adversities in middle-aged men who died by suicide. Several factors, such as mental and physical illness and alcohol misuse, confirm associations with suicide from previous research and are important to prevention in this group. Other antecedents, such as a history of violence and online harms we found in more men than expected.

  • We found evidence of much more help-seeking than expected, including in the week prior to death, with many men having been in contact with a range of services or agencies, mainly their general practitioner. This differs from previous studies and a commonly accepted notion that men do not seek help.

How this study might affect research, practice or policy

  • Services can contribute to suicide prevention in middle-aged men by improving recognition of risk when men present to services and by ensuring appropriate support tailored to their needs is available and accessible.

  • Recognition of financial stresses, and signposting to employment and debt advice and housing support, is also an important part of suicide prevention. Given the current global cost of living crisis and the increased burden this has historically placed on men, a suicide prevention priority must be to offer and maintain economic protections to groups we know to be vulnerable to economic adversity.

Introduction

Worldwide, male suicide rates are three times higher than those of women, with most high-income countries reporting the highest suicide rates in mid-life (45–55 years).1 2 In the UK, the USA, Australia, Canada and many other high-income countries, middle-aged men have the highest suicide rates,2–6 and are a major priority group for suicide prevention.1 They account for around a quarter of all deaths by suicide in England, Scotland and Wales, with over 1500 deaths each year.3–7 In the late 1990s, the highest suicide rates were in young men aged 20–34.3 Since 2010, there has been a shift in the pattern of age-related suicide rates; men aged 40–54 years are the group at highest risk.3 There are two main reasons for this change. First, as a direct effect of the 2008 global economic recession—when rising unemployment contributed to excess suicide deaths particularly in men, in England8 and across Europe and the USA.9 Second, it may represent a ‘cohort effect’; the impact of the earlier recession in the 1980s, when suicide rates increased substantially in young men, being carried with this same group into mid-life.10

Known factors associated with suicide in men include financial and employment stressors, limited social support including being unmarried, physical and mental ill-health (particularly depression), and drug and alcohol misuse.11–15 Richardson and colleagues’ 2019 systematic review emphasised the complexity of suicide in men and highlighted the need to understand how factors associated with suicide interact across the lifetime.15 Internationally, economic uncertainty has been linked to an increase in suicide rates, particularly in men8 16 17 and disadvantaged groups, such as those with existing mental health problems.18 A relationship between debt and physical and mental health, including suicidal behaviour, has also been established,19 with more severe debt being related to worse health outcomes.20 Studies have also cited that men may be less likely than women to talk about or report mental health problems, seek out beneficial support,21 or engage with services—especially in the context of employment, financial or relationship difficulties13 22 possibly due to stigma, pride or shame.18 21

Reducing and preventing suicide in men, particularly men in mid-life, is a UK-wide suicide prevention priority.23 National investment in suicide prevention through NHS England’s suicide reduction programme24 has seen local areas develop interventions for men, including awareness campaigns, mental health first-aid training, and short-term practical and emotional support aimed at tackling stigma and reducing suicide. Although it is too soon to evaluate the long-term impact of these projects on reducing suicide in men, previous campaigns have potentially increased public awareness and reduced stigma associated with mental health problems in general.25

We established a national study of suicide in middle-aged men to understand the stresses they faced prior to death that may be contributing to their high suicide rates and to record contacts with services as this could play a part in prevention. We also wanted to examine particular subgroups—men experiencing economic adversity, men with physical ill-health or a history of alcohol and/or drug misuse, men who had been bereaved, and men in contact with multiple agencies to investigate whether there were certain characteristics or antecedents of suicide that were more commonly associated with particular groups of men in mid-life. In this paper, we present findings from our examination of a range of investigations by official bodies that can occur when someone dies by suicide. These reports, including from coroners, the police and the NHS, provide detailed accounts from families, friends and professionals of the adversities being faced prior to death. Using these data, we aimed to: (1) examine the antecedents of suicide in middle-aged men aged 40–54, including the frequency of recent life events or clinical factors, and (2) investigate (a) the assumption that few middle-aged men would have been in contact with any support services or agencies in the context of the existing narrative that men do not seek help for their problems and (b) the presence of a combination of multiple stresses in particular subgroups of middle-aged men who died by suicide, using latent class analysis (LCA).

Materials and methods

Study population

We collected data about men aged 40–54 years (referred to as ‘middle-aged men’) who died by suicide (including probable suicide) between 1 January 2017 and 31 December 2017 in England, Scotland and Wales. Since 2010, men aged 45–49 have had the highest age-specific suicide rate, followed by those aged 40–44 and aged 50–54.3 7

Suicide deaths were notified to us by the Office for National Statistics (ONS; for deaths registered in England and Wales) and National Records for Scotland (for deaths registered in Scotland). Data from Northern Ireland were not obtained due to restrictions in the sharing of person identifiable data.26 As is standard for suicide research,27 we included deaths receiving a conclusion of suicide or intentional self-harm or events of undetermined intent. Deaths coded with the International Classification of Diseases, Tenth Revision (ICD-10) codes X60–X84, Y10–Y34 (excluding Y33·9) and Y87 were included. Any deaths receiving a narrative conclusion in England and Wales were included if ONS procedures applied one of the latter ICD-10 codes.

Sample

In 2017, there were 1516 men aged 40–54 who died by suicide in England, Scotland and Wales. We aimed to investigate factors associated with suicide in a random, stratified sample of approximately 20% of these men. This is based on our previous experience of the volume of these types of data it is possible for researchers to extract and analyse within the study period.28 Sampling was based on the proportion of individual deaths from (1) each age group (40–44, 45–49 and 50–54) and (2) each country. We used the SPSS random allocator function to select a random sample of 288 (19%) middle-aged men for investigation.

Data sources

We collected data about these 288 men from a range of investigations into their deaths by official bodies. We have previously used this methodology in an investigation of almost 600 suicide deaths in young people.28 In total, data were received for 242 (84%) of these men.

For deaths in England and Wales, we obtained audio copies of coroner inquest hearings (or copy statements or depositions, where unavailable). For deaths in Scotland, redacted Crown Office and Procurator Fiscal Service police death reports were requested. These present a concise summary of the circumstances leading up to death but are less detailed than coroner inquest hearings. We obtained information from coroner inquest hearings or police death reports for 228 (79%) deaths (194 and 34 deaths, respectively). For 12 deaths, the coroner (or equivalent) was unable (n=5) or did not wish (n=7) to provide data, and for 34 deaths, data were not returned within the study period. The content of the coroner inquest hearings varied depending on the complexity of the individual case but typically provided detailed personal testimony (ie, witness statements) from family and friends, police, postmortem and toxicology reports and, if relevant, medical evidence pertinent to the cause and circumstances of a death from primary and secondary care services.

The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) collects data on a UK-wide case series of people who die by suicide within 12 months of being seen by mental health services. A full description of the NCISH methodology has been previously published.29 Information from the NCISH database was obtained for 86 (30%) men identified as mental health patients.

We obtained 68 internal serious incident investigation reports from NHS services on patients who had contact within 12 months of death; 12 deaths had not met the criteria for review. For six deaths, data were not returned within the study period.

In England and Wales, the Prison and Probations Ombudsman (PPO) independently investigates the deaths of people in detention, residents in approved premises, and immigration detainees; these reports are published on the PPO website. In Scotland, deaths in prison are investigated at Fatal Accident Inquiries (FAI). The judgements of FAIs are published by the Scottish Courts and Tribunals Service. We identified three published criminal justice reports which matched men sampled in the study.

Procedure

A pro-forma, developed with advice from people with lived experience and based on our previous study,28 was used to extract information from the described data sources for aggregate analysis. Information was collected about demographic, medical, psychiatric, long-term and short-term (within 3 months of death) events that may have contributed to suicide risk. The last known contacts with general practitioner (GP), accident and emergency department (A&E) and secondary care services were also recorded. We recorded factors referred to in any of the data sources as present at any time or specifically in the 3 months prior to death (described as ‘recent’); presence suggests that a factor was relevant to the death but not necessarily causal. Variable definitions are shown in the online supplemental table 1.

A sample of 30 (12%) cases was reviewed by three researchers (CR, JG, SGT) and a Kappa Fliess interrater reliability test was performed, with initial agreement for individual items of 58–100%. Where there was disagreement, information was discussed and re-evaluated increasing concordance to 100%. Any areas of uncertainty in the remaining 212 cases were discussed with the team to ensure a consistent reviewing approach.

Statistical analysis

The denominator in all estimates was the total number of men where at least one data source was obtained (ie, 242 individuals), unless otherwise stated. Items of information not recorded in any data source were assumed to be absent or not relevant to the individual’s death. Pearson’s χ2 tests or Fisher’s exact tests (for cell counts less than five) were used to determine the association between particular subgroups of middle-aged men (including (1) men experiencing economic adversity (unemployment and/or recent financial and/or accommodation problems), (2) men with a physical health condition, (3) men with a history of alcohol and/or drug misuse, (4) men who had been bereaved, and (5) men in contact with multiple agencies (contact with three or more of primary care, justice system, mental health, or other services)), and key sociodemographic and clinical characteristics (such as marital and employment status, living circumstances, internet use, mental health diagnosis, self-harm, and service contact; 33 characteristics in total). The subgroups were based on prior knowledge and previous literature11–15 19 20 and compared with all other men not in that particular subgroup. We used the Bonferroni correction method when reporting statistical significance.30 This was at the 0.15% level (p≤0.0015) to account for the 33 multiple risk factors that were examined for each subgroup (0.05/33). Exploratory LCA was used to identify distinct classes (subgroups) of middle-aged men who died by suicide. We did this to determine potentially informative risk profiles based on the confluence of multiple risk factors which might inform specific prevention initiatives. Using logit LCA, we compared models that allowed for one to five latent classes and determined the best model fit using the likelihood ratio (G2) test and comparing Akaike’s information criterion (AIC) and Bayesian information criterion (BIC) values.31 The criteria for the best fitted model were when we failed to reject the null hypothesis for G2, in combination with lower values of AIC and BIC. Results from the LCA with p values less than 5% (p≤0.05) were considered statistically significant.

When reporting results we have suppressed cell counts under three, including zero, in accordance with ONS guidance on disclosure control to protect confidentiality. All analyses were undertaken using Stata software V.16·1.

Patient and public involvement

Three members of Mutual Support for Mental Health Research, a group of people with experience of self-harm, suicidality, or mental illness as either patients or carers, were involved in the research process by providing advice during the design of the study. They shared their insights and thoughts on the design of the proforma and data items. The group were not involved in the conduct or reporting of the study but were asked for feedback on key messages derived from the study’s findings.

Role of the funding source

The funders played no part in the design, data collection and analysis, or interpretation and writing up of the study.

Data availability statement

Data from this study are not available due to the sensitive nature of the research and information governance restrictions in place to protect confidentiality. A request to access data can be made to the Healthcare Quality Improvement Partnership: https://www.hqip.org.uk/national-programmes/accessing-ncapop-data/%23.ZEAOsOzMKAM

Results

There were 1516 men aged 40–54 who died by suicide in England, Scotland and Wales in 2017, 25% of the total number of suicide deaths (n=5950), 34% of all men who died by suicide in this year (n=4507; see online supplemental figure 1). From a 20% sample of all suicide deaths in middle-aged men in the study period (n=288), we recorded information on 242 (84%) individual deaths, mainly from coroner inquest hearings or police death reports (228, 79%). Information was recorded from a single data source (ie, a coroner inquest hearing (n=151), a police death report (n=22), or a serious incident report (n=13)) for 186 (77%) men, and from multiple sources (ie, two or more data sources) for 56 (23%) men; there were no major discrepancies between data sources.

Antecedents of suicide

Table 1 shows the features of suicide in middle-aged men. Sixty-seven per cent were unmarried (ie, single, divorced or widowed)—32 (13%) were divorced or in the process of a divorce, 45% lived alone. Six (2%) men were reported to have identified as gay or bisexual. A diagnosis of mental illness (mainly affective and anxiety-related disorders), previous self-harm and suicidal ideas or intent, physical health conditions, alcohol misuse and bereavement, including by suicide, were the most common factors related to suicide. Social isolation was recorded in 26 (11%) men. The most common recent life events were about relationships, money, housing and the workplace. Ten (4%) men were arrested within the week of death.

Table 1
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Sociodemographic and clinical antecedents and recent and long-standing risks of suicide in middle-aged men

Forty-two (17%) men had a long-standing history of family adversity, either through physical or mental ill-health. Four per cent reported historic childhood abuse, including sexual abuse (6, 2%). Twenty per cent were recorded to have a history of violence, 13% (n=32) in the 3 months prior to death. Seven per cent had experienced domestic violence. Suicide-related online experience was reported for 15% of men; mainly searching for information on suicide method (10%).

Table 2 presents the antecedents of suicide in particular subgroups of middle-aged men—those with economic adversity, a physical health condition, a history of alcohol and/or drug misuse, those who had been bereaved, or those in contact with multiple agencies—compared with all other middle-aged men who died by suicide who were not in that subgroup.

Table 2
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Antecedents of suicide in particular subgroups compared with all other men in the study

Economic adversity

Overall, 57% (n=139) of men were experiencing economic problems—unemployment, finance, housing—at the time of death. Of the 72 men who were unemployed, 34 (47% of unemployed men; 14% of the whole sample) had been unemployed for more than 12 months (defined as long-term). Twelve (17%) had recently lost their job. Recent financial problems included short-term and long-term debts (35, 14%), concerns about owing money (22, 9%) or ongoing issues with benefit payments (10, 4%). Six (2%) men had problematic gambling with or without associated financial problems. Twenty-one (9%) were facing eviction or had recently been evicted. Men experiencing economic adversity had higher rates of alcohol and/or drug misuse, suicidal ideation and/or intent and contact with a range of services, including mental health services and criminal justice agencies, compared with men who were not experiencing economic adversity (table 2).

Long-term unemployment (34, 14%) was combined with recent economic adversity (ie, finance and/or housing problems in the last 3 months) for 24 (10%) men. These men were more likely to be unmarried (23, 96% vs 138, 63%; p=0.001) with a history of violence) (11, 22% vs 12, 6%; p=0.001), and a mental health diagnosis (23, 96% vs 137, 63%; p=0.001) than men who were not experiencing long-term unemployment combined with recent economic adversity (n=218).

Physical health

Fifty-two per cent of men had a documented physical health condition (table 1), for 79 (33%) this had been present for at least 12 months. The most common conditions were diseases of the circulatory (eg, hypertension, 32, 13%), respiratory (eg, asthma and chronic obstructive pulmonary disease, 27, 11%), and digestive systems (eg, alcoholic cirrhosis of liver, 26, 11%). Comorbidity was common; 89 (37%) men with a physical health condition also had a mental health diagnosis, most often an affective disorder (45, 51%). Men with physical health conditions were more likely to be socially isolated, and to have been in contact with their GP than men with no known physical health conditions (table 2).

Alcohol and drug misuse

A history of alcohol and/or drug misuse was recorded for 49% of men. The most used drugs were stimulants (eg, cocaine, amphetamines, ecstasy; 17, 7% of the whole sample) and opiates/opioids (eg, heroin; 14, 6% of the whole sample). Many antecedents of suicide were more common in men with a history of alcohol and/or drug misuse compared with those with no history, including a diagnosis of mental illness, previous violence, suicidal ideas or intent, unemployment, contact with the justice system or mental health services, and bereavement. Recent workplace problems were less likely (table 2).

Bereavement

Thirty-four per cent of men had been bereaved by the death of a parent (66, 27%), family member or partner (24, 10%), or friend (6, 2%). Nineteen (8%) had experienced multiple bereavements and 14 (6%) had been bereaved by suicide. For most (67, 82%), the bereavement occurred more than 3 months earlier. Physical and mental illness in the family and unemployment was more common in bereaved men than men who had not been bereaved (table 2).

Service contact

For 220 (91%) men, there had been contact with front-line services or agencies at some time; most often with primary care (199, 82%). Fifty per cent (n=120) of men been in contact with mental health services, 30% (n=73) with the justice system (figure 1). Thirty-four (14%) had been in contact with the justice system as an offender of a violent crime, 17 (7%) as a victim, and 8 (3%) as both an offender and a victim. Ten per cent (n=25) had been in prison, including at the time of death (n=3), and 3% (n=8) had been in probation service contact. Contact with both drug and alcohol and employment services was less common. Figure 1 shows time elapsed since last contact with a range of different agencies. Sixty-seven per cent (n=162) of men were recorded to have been in recent (3 months) contact with services, mainly their GP (105, 43%); 38% (n=91) were seen in the week prior to death, mainly by mental health services (46, 19%). There were 22 (9%) men with no known contact with any services or agencies.

Figure 1
Figure 1

Service contact by time elapsed since last contact prior of death. GP, general practitioner; A&E, Accident and Emergency department.

Contact with multiple agencies (ie, contact with three or more of primary care, justice system, mental health, or other services) was recorded for 41 (17%) men. Men in ‘multiple contact’ had higher rates of self-harm and suicidal ideas, previous violence, a history of alcohol and/or drug misuse, and unemployment than men not in contact with multiple agencies (n=201; table 2). A diagnosis of schizophrenia or other delusional disorders was also more likely compared with men not in contact with multiple agencies.

Latent class analysis

Three distinct types of middle-aged men who died by suicide were identified using LCA with 14 suicide risk indicators, both in terms of numerical indicators of fit and class group interpretation (likelihood ratio G2=−2206.3, AIC=4512.5, and BIC=4686.9; table 3). Class 1 represents 26% (n=62) of the sample of middle-aged men who died by suicide. Classes 2 and 3 both represented 37% (n=90) of the sample. The characteristics of these subgroups are shown in table 3.

Table 3
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Latent class analysis—subgroups of middle-aged men who died by suicide based on probabilities (%) of sociodemographic and clinical characteristics present in each class

Class 1: unemployed, unmarried men who lived alone (26% of the sample)

Middle-aged men in class 1 had the highest probability of being unmarried, unemployed and living alone compared with any other class. Recent life events were also less prominent. They were most likely to have a diagnosis of mental illness and a history of alcohol and/or drug misuse. Members of this class were also more likely than middle-aged men in class 3 to have been in contact with mental health services at some time.

Class 2: men in mental health service contact with recent adverse events (37% of the sample)

Members of class 2 were most likely to have been in contact with mental health services at some time compared with all other classes. They were also most likely to have previously self-harmed, have a physical health condition, a history of violence, have been bereaved and to have used the internet in a way that was suicide-related prior to their death. Recent relationship, workplace and finance problems were more likely compared with other classes.

Class 3: men in employment (37% of the sample)

Middle-aged men in this class were least likely to be unemployed compared with other classes. They were also less likely than men in other classes to have evidence of a range of other stresses and recent events prior to death such as a history of violence, previous self-harm, alcohol and/or drug misuse, a diagnosis of mental illness, contact with mental health services, or recent financial problems.

Discussion

Main findings

In this study, we identified multiple stresses and adversities in middle-aged men who die by suicide. Several factors, such as mental and physical illness, alcohol misuse, social isolation and relationship problems, confirm associations with suicide from existing research11 12 14 15 and are important when considering prevention in this group. Other antecedents, including a history of violence, bereavement and online harms, we did not expect to find in as many men as we did. Comorbidity was also common; over a third of men reported both mental (mainly depression) and physical health condition(s) (mainly circulatory problems), which were often long term. Economic pressures were reported in over half of the men we examined, including unemployment (including a significant minority unemployed for over 12 months), financial or accommodation problems.

We found evidence of much more help seeking among middle-aged men than expected. Over two-thirds of men in our sample had been in recent contact with a least one support service or agency, including over a third within a week of death. Half had been in contact with mental health services and almost a third with the justice system. This differs from previous studies32 and a commonly accepted notion that men do not seek help.13 32 However, not all risks were addressed by contact with services—very few men had been in contact with employment services (2%) and 14% with specialist drug and alcohol services despite the high rates of unemployment and alcohol and/or drug misuse (30% and 49%, respectively) we found.

LCA revealed three subgroups of middle-aged men who died by suicide, each with different risk profiles. Men in class 1 showed evidence of chronic social and economic stress (unemployment, being unmarried, living alone) and psychiatric and physical morbidity. For men in this class, recent life events were less prominent. Men in class 2 had the lowest probability of all classes of being unmarried or living alone, indicating a higher likelihood of social support and fewer social stressors, but recent adverse events were more prominent, as were physical and mental ill-health. Class 3, who could perhaps be viewed as a residual group, were employed men who were less likely to have common risk factors for suicide, such as previous self-harm, or evidence of recent adversity.

Interpretation of findings

Economic stress is a powerful driver for mental ill-heath and suicide. International evidence has shown the association between previous economic downturns and increased suicide rates, particularly for men in both the general and patient populations.8 9 17 22 In the UK, for example, the suicide rate in men began to increase around the time of the 2008–2010 economic recession.8 Our findings suggest, for men, economic factors may be more important than clinical ones—many of the men we examined had experienced either long term (ie, longstanding unemployment) or recent (ie, financial or accommodation problems) economic adversity, 1 in 10 had experienced both. Whereas many of the wide-ranging antecedents we found are known factors in suicide, they are not necessarily causes of the post-2010 rise in suicide rates in middle-aged men. Although no two recessions are the same, this has important implications for prevention considering the current global cost of living crisis which has seen the price of food and energy increase beyond the incomes of many.33 Middle-aged men often view employment and financial success and security as central to their identity, the loss of a job, money and housing problems, therefore having a greater impact on them than on women or younger men34 Consequently, substantial and long-term economic support and targeted interventions are important suicide prevention measures for middle-aged men who are particularly vulnerable to economic volatility, especially during periods of economic crisis. For services, assessing financial stresses, and signposting to employment and debt advice and housing support are vital to help reduce risk. More fundamentally, long-term policy and political effort to tackle the structural aspects of the economy that contribute to income inequality, such as low pay, high housing costs, and the declining value of working age benefits, may also have a role in prevention.

Over two-thirds of the men we examined were unmarried, 13% were divorced or in the process of becoming divorced. Middle-aged men often depend on their partners for emotional support, and they tend to have fewer friendships than their younger counterparts.35 Divorce can leave them isolated, separated from their children and displaced from the family home, increasing their risk of suicide. These are all factors identified in the suicide deaths of several of the men in our study. Men who are unemployed or experiencing financial difficulties are also known to be at greater risk of relationship breakup, alcohol misuse and social isolation36 and this is confirmed by our findings. Addressing isolation and enabling men to strengthen their social relationships, not only with significant others but more broadly with friends and the wider community, is therefore key to suicide prevention in this group.

Of course, there are some middle-aged men who die by suicide without explicit indications of risk. We found a group of men (class 3 in our LCA) who had fewer stressors, such as unemployment, self-harm and mental illness. For them lesser degrees of distress may need to be recognised by services, employers and families. There were also some men (class 2 in our LCA) who appeared to have emotional, social and economic support (as indicated by being less likely to be unmarried, living alone and unemployed), but where suicidal feelings may have escalated rapidly as a response to a recent problem in the workplace, with a relationship or because of money worries. Addressing risk that develops rapidly is therefore another important prevention measure for this group. Professionals should be aware of different groups of middle-aged men where risks might cluster. Although we acknowledge it is important for further research to explore the validity and stability of these groups over time.

The findings of this study make apparent the collective influence of stresses and adversities for suicide in middle-aged men. In isolation, these events may not seem severe and on their own suicide risk may not be recognised. Some stresses faced by men in mid-life may be long-standing risks from childhood or adolescence, and others may arise later in adulthood (eg, long-term unemployment, poor physical health, alcohol misuse, a lack of protective factors such as social support or being in a relationship) before suicide occurs as a reaction to a crisis or a ‘trigger’ event (such as loss of job, end of a relationship or justice system contact). This pattern provides corresponding opportunities for prevention such as long-term public health initiatives to encourage help-seeking for specific stressors, support in mental healthcare, alcohol and drug and self-harm services, as well as socioeconomic interventions (such as social supports, and economic protections), and a society-wide awareness of risk. However, we do acknowledge further research is required to offer more rigorous support of cumulative risk in middle-aged men who died by suicide, such as has been done for adolescents and young people.37

Contrary to the existing narrative, our findings suggest men are seeking help, but that support may not be being offered in a way that addresses or is suited to their needs. Many of the men we examined were in recent contact with a range of different support services and agencies prior to death. We suggest that there is a need to ensure services for men are fit for purpose and offer practical and emotional support specific to their needs. A joined-up approach to health and social care, the recognition of indirect risk, and enquiring about mental health are all important parts of suicide prevention in middle-aged men, especially in places where men are seen most often—GPs, A&E, the justice system and mental health services. There is limited evidence that support services offering men an opportunity to contribute or cofacilitate, that focus on a shared goal, offer peer support, or are community based having been developed by men themselves or by the voluntary sector (eg, Men’s Sheds) are key to keeping men engaged, although these insights need further investigation.36

Strengths and limitations

Our findings combine information from a range of official investigations that can occur when an individual dies. This methodology, which has been used in a previous study,28 allowed us to obtain a comprehensive picture of the complex range of adversities middle-aged men faced prior to their death. However, several limitations should be considered. First, the study was an observational and not a risk factor study. It was not designed to allow the use of a control group. We have, however, drawn comparisons with available general population figures (using the closest matching age group data), such as unemployment, divorce, drug and alcohol use estimates. Many of the characteristics and antecedents we identified occurred at a higher frequency in our sample of middle-aged men compared with their incidence in the general population (table 4). To conduct a study of this kind as a controlled study would be challenging, in part because of the ethical implications in contacting families. The fact of suicide itself, its impact on disclosure and the reluctance of potential controls to be interviewed could also distort any comparison.38 Although this was not a risk factor study, it does describe the adversities middle-aged men were facing prior to suicide from information discussed at inquest (and from other sources) and identified potential targets for prevention. Second, some figures may be overestimates as families and others focus on the factors they see as most relevant and ‘search for meaning’ after a suicide, whereas other factors may be underestimated, particularly in sensitive areas (such as childhood abuse, sexuality, gambling and bullying). We also acknowledge that while we identified and reviewed a wide range of antecedents, this may not be comprehensive. When data on a particular antecedent were not reported in a data source, we assumed that it was unlikely to be present and thus recorded it as absent for analysis. Third, information may be subject to recall, information or ascertainment bias, and completeness and content detail also varied because the data we used were not designed for research purposes. This meant we were unable to obtain complete and consistent data on, for example, medical and psychiatric history. Fourth, our findings cannot be linked causally to suicide, but they do tell us about the stresses middle-aged men face prior to death—this information having been reported because the informant or coroner felt they were relevant to the person’s death. Fifth, our findings are exploratory and we made multiple comparisons. To account for this, we used the Bonferroni correction method and only reported findings at the 0.15% level (p<0.0015) as statistically significant. Sixth, although the sample size (20% of all deaths in middle-aged men in 2017) was based on researcher capacity to obtain, extract and analyse data within the study period, as informed by previous studies with a similar methodology,28 it was smaller than some other international studies examining suicide39 and limits the number of individual deaths we were able to include in the analysis. It also means for some variables (eg, historic childhood abuse, sexual orientation) cell counts were low, being able to determine the possible presence of these factors in more cases would increase statistical power and make the findings more robust. Seventh, 2017 was the most recent full calendar year for which data were available at the time the study was undertaken. Men in midlife continue to have the highest suicide rates in the UK,3 and findings from this sample remain relevant to this age group. Finally, the findings are aggregated for England, Scotland and Wales with no country-specific figures, and may be driven by the larger number of deaths in England.

Table 4
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Comparison of key antecedents for suicide in a sample of middle-aged men who died in 2017 (study sample), by available general population figures

Conclusion

The range of stresses we identified prior to death by suicide in middle-aged men highlights that suicide is complex, and often associated with a combination of long-standing risks and recent events, many of which are socioeconomic in nature. What does this mean for prevention? Prevention starts with the way we support young men throughout their childhood and adolescence through family and parenting support, it continues into the services and support that are offered as these men age and their exposure to adversity builds. This includes mental healthcare, self-harm and alcohol and drug services, and bereavement support, and the immediate and urgent availability of crisis services, social supports and the awareness of risk across agencies. Two-thirds of the men in our study had been in recent contact with a range of support services or agencies. It is oversimplistic to say that men do not seek help. Instead, we should focus on how services, particularly GPs, mental health services and the justice system, can improve recognition of risk and respond to the needs of men, and work better together. Finally, many of the men we examined were experiencing economic adversity. We know economic stress is associated with increased suicide risk. Given the current cost of living crisis in the UK, a prevention priority must be to offer and maintain protections to those groups we know to be most vulnerable. Following the COVID-19 pandemic, when labour market and economic protections are thought to have protected against an increase in suicide,39 there is now general consensus that there is a risk of a global recession and, although not inevitable, suicide risk may increase in groups known to be vulnerable during previous economic downturns (ie, middle-aged men). During this economic downturn, an approach that encompasses economic, public health, health and social care measures with responsible media reporting and suicide surveillance is essential to preventing an increase in suicide.40