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Suicide in men: Suicide prevention for the male person 

Suicide in men: Suicide prevention for the male person
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Suicide in men: Suicide prevention for the male person
Author(s):

Wolfgang Rutz

and Zoltán Rihmer

DOI:
10.1093/med/9780198570059.003.0035
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Abstract

Male life expectancy in Europe is between 5–15 years lower than that of women. This might, in part, be related to the fact that men in general approach and consume medical services only half as often as females. Between 70–90 per cent of all suicides are committed in a clinical condition of major depression and, paradoxically, men commit suicide 3–10 times more often than women in spite of being only half or less frequently diagnosed as depressive than women. Male depressive symptoms are different from those reported by females, mainly because of men's alexythymic difficulty in recognizing and reporting depressive symptoms. In addition, male depression can manifest itself as abusive, aggressive or antisocial behaviour. Moreover, in the case of suicidal behaviour, males more frequently use violent or lethal methods. Training of health care workers on earlier and better detection of male depression (including the use of the Gotland male Depression Scale) and increasing public awareness for depression are promising tools in the prevention of suicide in males.

Morbidity and mortality in European societies—a question of male ill-being and suicide

Both genders define and influence each other's identity and societal situation. This means that men and women in a societal and individual crisis situation often become each other's problem, which can cause violence as well as suicide, abuse, risk-taking behaviour and stress-related somatic disorders. Thus, increasing the understanding and communicative ability, as well as social interaction between the two genders on a political level, in society at a whole, in families and between individuals seems to be one of the best health promotional activities. Such efforts should be made in parallel with improving early detection and possibilities for therapeutic intervention, especially concerning common but atypical conditions of ‘male depression’ as well as depression related to aggression and suicidality.

Danish men commit suicide seven times more often than women do during the first year after a divorce (Qin et al. 2000). Male life expectancy in the WHO European region is between five and fifteen years lower than that of women, and a widening gap between female and male life-expectancy seems to be a reliable indicator for an increasing stress load in a society (WHO 2005). In the European Union, mental ill-health is considered to be ‘Europe's unseen killer’. The European Commissioner for Health declares that ‘the societies we have created generate mental ill health’, and the mental ill-health related and stress-related mortality in Europe is predominantly a male problem (European Commission 2005; WHO 2005).

In some Eastern European societies that are undergoing heavy and dramatic transitions, male life expectancy decreased during the 1990s within one decade by more than ten years, whereas female morbidity and mortality patterns remained unchanged. Increased numbers of suicide were one of the most important contributing factors to the decrease in male life expectancy (Wasserman et al. 1994; Notzon et al. 1998; Värnik et al. 1998; Rutz 2001).

The examples above may lead us to believe that males are more vulnerable than females in times of stressful transition and change. Looking at male suicide figures as the expression of mental ill-being, and comparing them to female suicides in Eastern Europe's countries of transition, we find that females seem to be more protected in times of change. Male suicidality seems to reflect almost unequivocally the stress load in a society, often related to challenged traditional role expectations and status losses in society, working places and as family providers (Taylor et al. 1998; Qin et al. 2000). It strongly correlates with mortality due to violence, risk-taking, accidents, injuries and cardio- and cerebrovascular disorders, a mortality that increased five to nine times compared to that of women.

Determinants of mental health

There is consensus in the medical world today that the following conditions are crucial determinants for physical and mental health (Wilkinson and Marmot 1998): a sense of control, that is, the absence of helplessness; a feeling of social connectedness and significance, i.e. the absence of alienation, marginalization and social deprivation; a sense of cohesion, that is to say an absence of meaninglessness and existential emptiness; and finally, the feeling of dignity, status and integrity in life.

It is known from animal trials that males and females respond to stress differently (Jackson et al. 2005). The loss of social significance seems to be the most important risk factor in women, whereas males are especially sensitive to impairments in societal status and dignity (Taylor et al. 1998). Male individuals are most sensitive to hierarchical degradation, whereas females react more strongly to social deprivation and the loss of family cohesion. A recent Danish study on more than 800 suicide victims found that beside mental illness, which was the strongest risk factor for suicide for both genders, unemployment, retirement, being single and sickness absence were significant risk factors for men, and having a child at home was a significant protective factor for women (Qin et al. 2000). Related to this, there are indications that stressful societal and even individual transition in life due to unemployment and the loss of the capacity to be the family provider heavily afflicts males, whereas women even in times of crisis and transition often have the protective capacity to retain social networks, family responsibility and a feeling and ability to create control and meaning in life (Taylor et al. 1998; Qin et al. 2000).

Gender related public health paradoxes

Two paradoxes of public health can be detected in Europe today. First, men in general approach and consume medical services, with the intention to ask for help only half as often as females, yet die, five (European Union) to fifteen (Russian Federation) years earlier than women (WHO 2005). The second one is attributed to the gender specificity of depression and suicide. We know today that between 70–90 per cent of all suicides are committed in a clinical condition of major depression and a consecutive depressive distortion of emotional and cognitive perception (Wasserman 2001; Rihmer et al. 2002). Paradoxically, men commit suicide three to ten times more often than women (Isometsa and Lönnqvist 1998; Wasserman 2001; Rihmer et al. 2002; Levi et al. 2003), despite being diagnosed as depressive only half as often, or less, as women (Picinelli and Wilkinson 2000; Szádóczky et al. 2002). Suicide attempts are much more frequent among females, yet males are markedly over-represented among suicide victims, and one of the explanations could be their use of more violent/lethal methods (Isometsa and Lönnqvist 1998; Wasserman 2001; Rihmer et al. 1995, 2002; Levi et al. 2003). The probable factor behind this is the failure of detection of male depressive conditions (Rutz 1999).

An exception from the European male preponderance of committed suicides can be found in central Asian and Asian countries, such as Kazakhstan, Kyrgyzstan, China and India. In these countries, young females are heavily exposed to the social consequences of gender role transition. In China, suicide-preventive subjection of females due to responsibilities for family and children has been weakened due to birth control and family restrictions (Yang et al. 2005). Furthermore, the easy access to heavily poisonous pesticides and insecticides is widespread.

Today, there is epidemiological evidence as well as clinical experience that the prevalence of diagnosed depression is inversely correlated to the frequency of suicide (Rihmer et al. 1993). Such evidence contrasts our knowledge about the specific and causal links between depression and suicide (Wasserman 2001; Rihmer et al. 2002) that would suggest an increase of suicides when depression more frequently occurs. This ‘prima vista’ paradox can only be explained by the postulate that adequately diagnosed and acknowledged depression leads to adequate treatment, thus preventing ‘depressiogenic’ suicides (Rihmer and Akiskal. 2006). In accordance with this, Hungarian research shows that a statistically low prevalence of diagnosed depression in a population correlates with a high number of committed suicides, but also that a high number of recognized and consequently properly treated depression correlates with a lower suicide frequency (Rihmer et al. 1990, 1993; Rihmer 2004a; Berecz et al. 2005). These findings have been replicated in different studies. They show that improvements of the detection and monitoring of depression, e.g. through education of professionals in primary health or psychiatric care, but also by awareness raising activities in the society as a whole, often result in an increase of specific antidepressive prescriptions to an adequate population level and are correlated with lowered suicide rates (Rutz et al. 1990, 1997; Rihmer et al. 1995; Isacsson 2000; Oravecz et al. 2003; Rihmer 2004a; Grunebaum et al. 2004; Ludwig and Macrotte 2005; Rihmer and Akiskal 2006; Henriksson and Isacsson 2006). However, one must be conscious of methodological fallacies when analyses are performed on an aggregate level (Khan et al. 2003; Ferguson et al. 2005).

Symptoms of male depression and suicidality—a question of gender specificity?

Male depression is often overlooked and not recognized, due to one or many of the following reasons: concomitant abusive and alcoholic behaviour, drug addiction, poor impulse control and an aggressive and violent acting out that misleads to an incomplete diagnosis of personality disorder, psychopathy or addiction (Rutz et al. 1995, 1997). Apparently, male depressive symptoms are different from those symptoms generally reported by females. Diagnostic criteria in conventionally used depression assessments are most often developed on the basis of reported symptoms of depression (Wasserman 2006). Such criteria could be inadequate or non-sufficient in male depression because of men's alexithymic incapacity to acknowledge depression and to report depressive symptoms (Rutz et al. 1997).

Two large-scale, community-based epidemiological studies showed that untreated depressive males reported depressed moods significantly less frequently than females, and that depressive males report fewer symptoms than females (Angst et al. 2002; Szádóczky et al. 2002). In addition, Angst et al. (2002) also found that there were marked gender differences in coping style: men coped by increasing their sports activities and consumption of alcohol and tobacco and women through emotional release, religion and reading. The high degree of abuse in males related to their helplessness and depression points to self-medication in the absence of specific help, where, for example, the alcohol consumption in a vicious circle reinforces the depressive underlying condition (Bech 2001; Angst et al. 2002).

Lower prevalence of depression in males—an artefact?

In the American Amish population, aggressive and violent acting out as well as addiction and alcohol abuse are strictly stigmatized (Egeland et al. 1983). Similarily, in many American Jewish communities, as well as among Israeli orthodox Jews, alcohol abuse is taboo and considerably less frequent than in other ethnical and religious groups (Levav et al. 1993). Interestingly, the rate of depression in these populations is as high in males as in females, and suicide figures are equally low in both genders.

On the other hand, in those European countries where alcohol abuse frequently exists and has a relatively low stigma, the prevalence of female depression is considered to be two or three times higher than in males. Male completed suicides, however, are two to three times more frequent than in females (Picinelli and Wilkinson 2000; Wasserman 2001; Szádóczky et al. 2002; Angst et al. 2002; Rihmer et al. 2002; Levi et al. 2003.) Alcoholism that may camouflage depression is nine to ten times higher in Russian males than in females. Accordingly, the female to male ratio in completed suicide is 1:6 (Wasserman et al. 1994) and depression in certain Russian male populations are hardly ever diagnosed (Levi et al. 2003; Krasnov 2004). This, again, may exemplify the problematic under-diagnosis of depression in males resulting in high male suicide rates.

Thus, the following question can be asked: are European men today, as shown in Hungarian research (Rihmer et al 1990, 1993), under-treated and under-diagnosed in their depression and, therefore, ‘over-suiciding’ and exposed to the self-destructive consequences of risk-taking, self-neglecting and careless behaviour? Is the preponderance of female depression explained by insufficient diagnostic and therapeutic efforts in relation to depressed men, and as such an artefact? Can a solution be found through the improvement of the diagnosis and treatment compliance of depressive males?

Problems of detecting male depression and suicidality

The WHO collaborative study ‘Psychological problems in general health care’, performed in 1991 on more than 25,000 primary care patients in 14 countries found that only 15 per cent of the patients with ICD-10 diagnosis of major depression were recognized as such by their general practitioners (Lecrubier 1998). However, more recent studies from the United States and Europe report a higher rate of recognition (Berardi et al. 2005). Considering the above, the recognition and treatment of the atypical male depression in medical and social services is still problematic. The biggest challenge, however, seems to be to identify depressive and suicidal males outside all supportive services, the ones who do not seek help, and who sometimes act out and often self-medicate their depression through addictions or addictive comportments such as gambling, fighting, excessive exercise, ‘workaholism’ or hypersexuality. This challenge is emphasized in a recent community study from Australia reporting that in both adolescents and adults the belief that one can deal with depression alone (i.e. without medical help) was significantly associated with the male gender. A less favourable view regarding mental health professionals could be detected, and a more favourable attitude toward substance use, such as alcohol, nicotine, marijuana, to cope with depression was widespread among men (Jorm et al. 2006). Another large-scale Australian survey also showed that compared to females, males more frequently contended with their suicidal crisis by an over-consumption of alcohol and or a misuse/overuse of drugs (De Leo et al. 2005).

Males suicides—the case of Lithuania

According to WHO data, the highest suicide rates in the world can be found in the Baltic States, especially in Lithuania, predominantly in rural areas characterized by high male alcoholic consumption, a low degree of male help-seeking and low prevalence of diagnosed and statistically registered depression in males.

Suicides in Lithuania are in 90 per cent of all cases committed by males, generally in the countryside. In order to tackle this issue, crisis intervention centres have been established in most communities, professionally staffed and working intensively around the clock. The problem is, however, that 80–90 per cent of their clients are female, and the suicide figures remain as high as before. However, the centres have existed for no longer than a few years, and results of intervention activities take time to evaluate correctly (O Davidoniene, personal communication 2005).

The lesson here is that male suicidality has to be met by innovative approaches. Availability and accessibility of services is not enough: they have to be acceptable and adapted to value systems favouring traditional and, worst, stagnant views on masculinity and the male self-imagination. However, to create services acceptable to male farmers and fisherman exposed to dramatic stress and work insecurity in a countryside in transition is not an easy task. Non-conventional platforms and arenas have to be used—the workplace, public spaces, religious congregations, sports clubs or trade union associations. Additionally, the willingness and engagement of relatives and friends to invest in socially difficult and life-threatening situations is essential.

Suicide, aggression and violence

Male suicidality can be studied through the quite intricate context of depression, suicide, auto-aggressive self neglect and hetero-aggressive violence. Together with suicides, homicides in Russia have increased nine times during the 1990s, in parallel with an increase of alcohol intoxication related deaths, accidents and cardio- and cerebral vascular mortality (Rutz 2006). In the Balkan countries, especially in Islamic cultures, suicidality is relatively rare, even in times of societal stress and inner conflicts. Instead, premature mortality due to cardiovascular disorders, accidents, and homicides have increased dramatically since the conflict in former Yugoslavia, mainly related to different types of addiction as well as to aggressive behaviour and general misconduct (A Marusic, personal communication 2004). In Latin American countries, depression in males is also rarely diagnosed and the prevalence of female depression is up to ten times higher. However, aggression, violence, homicide and alcoholism, but not suicides, are to be found up to ten times more often among males (I Levav, personal communication 2004.)

The interrelationship between depression, suicide, abuse and violence is elaborated in the WHO's World Health Report on Mental Health 2001 and the World Health Report on Violence 2003. Both reports point to the idea that an increase of male suicidality and a high prevalence of aggression, family violence, male carelessness and self-destruction could be related to male depression, and could be tackled by an improvement of detecting, treating and monitoring male depressive conditions (WHO 2001, 2003).

What can be done? The Gotland experience

An educational approach on the prevention, treatment and monitoring of depression and suicide was directed to all general practitioners on the Swedish island of Gotland from 1984 to 1985 (Rutz et al. 1990, 1997). A drastic increase of suicidality during the 1970s and early 1980s led to a situation that primary health care doctors no longer felt able to deal with. On their demand, a comprehensive educational programme was started that resulted in a significant improvement of the GPs ability to detect and treat depressive conditions. The outcome was an obvious decrease of completed suicides and violent suicide attempts on the island, together with a decrease of depression-related morbidity, workplace absence and health care consumption. However, the positive results almost exclusively concerned the female depression-related suicides (Rihmer et al. 1995). Male suicidality was unchanged and remained very high (Rutz et al. 1995, 1997).

The findings of the Gotland Study have been replicated in Jämtland county in Sweden, which also showed that the improvement in the treatment of depression and preventing suicide was more pronounced in women (Henriksson and Isacsson 2006).

To investigate the reasons for the unchanged male suicide rate, a psychological autopsy was performed on all male suicides committed on Gotland after the educational intervention. The study showed that the male suicide victims were unknown to the medical system, be it the psychiatric one or the primary care one. The men had not asked for help, but appeared to be quite disturbed on a personal level to themselves, their families and friends and the police, to taxation authorities and to the social welfare system, especially the units for alcohol and addiction. The men displayed misconduct through frequent verbal and physical manifestations of aggression, irritation, dissatisfaction, disturbed personality traits and a subjective feeling of uneasiness as well as bad impulse control together with abuse and a general negativism. They were generally not seeking help and had, in the few cases of seeking assistance, a non-compliant attitude to eventual treatment attempts (Rutz et al. 1995, 1997; Rutz 1999).

When a scientific evaluation of the original educational intervention was finalized in1994 and showed the described positive results on female suicides (Rihmer et al. 1995), a programme, of continued education on depression was started in 1994 and offered to the general practitioners on Gotland. In this programme, information about the male depressive and suicidal syndrome was added and given to primary health care, but also to other caregivers and the general population, by dissemination via mass media and in complementary educational programmes. The public response was mostly from women asking for help for male relatives who they easily could recognize in the published descriptions of male depression and suicidality (Rutz et al. 1997; Rutz 1999). However, this was enough to motivate an increasing number of males to seek and keep therapeutic contact with the medical system and get their depressive and suicidal condition treated. As a result of this approach, the number of male suicides on Gotland significantly decreased for the first time in the mid and late 1990s (Rutz et al. 1997).

Improving the recognition, early intervention and monitoring of male depression and suicidality

Males hardly ever report depression, depressive feelings or symptoms. Therefore, screening instruments in primary care and other medical settings should be used. An assessment instrument for male depression, the Gotland Male Depression Scale (see the Appendix to this chapter), can detect the phenomenology and depressive symptoms that have been found to be typical of depressed and suicidal males (Rutz 1999; Wälinder and Rutz 2001). Such symptoms have been considered atypical, and thus have been overlooked in a medical world where therapeutic efforts depend on the gender bias in the diagnostic efforts. The subsequent lack of awareness and incorporation of gender data lead to blind spots, and a failure to see the differences as well as similarities between men and women in experience, conditions and symptoms. Today, the Gotland Male Depression Scale has been scientifically validated; it is translated into different languages and is met nationally and internationally with increasing interest. It is with good results used as a screening instrument in primary health care, but also by social welfare authorities in the treatment of masked depression in alcoholics and substance abusers, even among young men (Bech 2001; Zierau et al. 2002; Möller-Leimkühler et al. 2004). In addition to conventional depression diagnostic instruments in primary care, the Gotland Male Depression Scale is a helpful tool. Another useful screening method is the WHO 5 Well-Being Scale, which does not ask for depressive symptoms, but for a greater or lesser state of well-being in ways that those who is not used to verbalizing emotions appear able and willing to answer. This scale has been used in different large investigations, and it is one of most useful first screening steps to a diagnosis of male de-pression, even in non-medical arenas (Bech 2001, Möller-Leimkühler 2002). The engagement of families, friends and partners is also necessary (Wasserman 2006).

However, since the majority of the symptoms of male depression—irritability, anger attacks, aggressiveness, etc.—are also the leading features of mixed depression (three or more intra-depressive hypomanic symptoms in the frame of ‘unipolar major depression’), it has been suggested that male depressive syndrome could be strongly related to the bipolar mood spectrum (Rihmer 2004b). However, the eventual gender specificity of the different types of bipolar mood disorders are still unclear and further investigations are needed. A link can be detected from the male depressive syndrome to the concept of a stress-provoked, cortisone-induced serotonin-related anxiety-driven depression, and studies suggest a male preponderance of such depression (van Praag 2004; Rihmer 2004b).

Prevention measures in public spaces

To improve, alert and sensitize the health care system is not enough. Depressive, aggressive, violent and abusive males often generate immense problems for themselves and their close environment. Such men should actively be searched for in order to prevent suicides and domestic violence, as well as depressive, self-destructive and careless risk-taking and its consequences. Areas of such intervention should be public spaces such as workplaces, restaurants, social networks of friends and families, trade unions, sport associations, political organizations, but also institutions for abusers and criminals.

Activities should focus on sensitization, motivation, awareness, education and capacity building, by lecturing and networking in professional structures that are capable of intervention, treatment and monitoring follow-up.

Specific services

Furthermore, society's unrealistic self-ideation of conventional masculinity, e.g. ‘to always be strong’, needs to be questioned. It is probable that men's ability to ask for help would be increased after cognitive programmes focusing on such issues. Such programmes could also play a curative role. However, it is especially important to create services where trained staff with a high degree of apprehension and the ability to see beyond stereotypes, recognizing and supporting male patients with broken or lost identities and/or rampant traditional masculinity.

Design services

An additional problem here is that outpatient services in psychiatric and mental health care are often aimed at the female patients, as most of the outpatients in psychiatric services are females. Psychiatric and mental health care professionals may be unprepared to recognize and deal with the indications of male depressive pathology because of blind spots of gender-bias in medical practice. Also, the employment of female professionals is widespread in the mental health care arena, in part because it has traditionally been a female profession, one that is of low status and low pay. Perhaps these female professionals may be even less equipped to identify male depression because of their sex, although there are no studies or findings to confirm such statements.

Thus, in this vicious circle, a situation appears in which the frequency of help-seeking at psychiatric services does not reflect the real prevalence of mental ill-being, suffering and depression in males. An example: psychiatric and outpatient mental health services in many countries presuppose typical features of female help-seeking, such as motivation, compliance, insight and the willingness to change as inclusion criteria for offering help, thus excluding those patients who act out and behave abusively. These demands may be hard to fulfil by males (or females) in deep trouble who are desperately acting out suicidal depression.

One result of this gender-related imbalance is an artificial situation in many countries, where the huge majority of compulsive, custodial and forensic inpatient services are utilized by males, whereas 80 per cent of supportive psychiatric and mental health outpatient care facilities are consumed by females. Another is the poor treatment rate of depressed men, which is the consequence both of their less frequent treatment-seeking behaviour and lower recognition rate (du Fort et al. 1999; Angst et al. 2002; Möller-Leimkühler 2002). This again points to the importance of not only considering the accessibility, but also the acceptability of services when designing structures of service provision. The former is also true for suicidal persons. An extensive literature review (Luoma et al. 2002) shows that the rates of medical contact during the last year among suicide victims are much higher for primary care providers (77 per cent) relative to mental health services (32 per cent), and this rate is much higher for females than for males. Looking at the medical contacts in the last four weeks before suicide, the figures for females are 45 per cent and for males 19 per cent, respectively. It has also been demonstrated that the widespread use of antidepressants in the new ‘SSRI-era’ is particularly striking for women who, compared to men, seek more help for depression (Rihmer and Akiskal 2006).

It should be said that male depression can be treated and male suicides can be prevented. Antidepressive pharmacological interventions seem to be effective on male depression and suicidality, provided they are initiated and given by empathic and understanding services that create compliance and are embedded in a holistic approach.

Some scientific challenges

The shortcomings in male help-seeking behaviour, and the health care professionals failing in identifying such behaviour when help is actually sought, as well as men's lack of compliance to treatment and preparedness to show weakness, leads to the delineation of gender-specific types of ‘suicidal behaviour’ in research. Such gender types are intrinsically linked to a wide range of sociocultural categories and specificities such as age, ethnicity, demography, sexuality, and such cultural phenomenon of identification, social images and belonging have to be considered. In the case of gender-specific types, one can detect two large groups: one completing suicides or committing aggressive, decisive suicide attempts that often are failed suicides, consisting predominantly of males, and another committing repetitive, multiple and less intentional acts of self-harm, consisting mainly of females (Isometsa and Lönnqvist 1998; Wasserman 2001; Rihmer et al. 2002). In the second group, many suicide attempts have the character of a ‘cry for help’ (Farberow & Schneidman 1961) and are often suicide-preventive as such (Rutz 2003). Consequently, it is scientifically questionable to put completed suicides and multiple suicide attempts together in a category of ‘suicidal’ or ‘self-harming’ behaviour for the purpose of creating a scientific context. This is, however, often done today, for example in investigations regarding outcomes of treatment studies, in order to gain statistical power in a research setting where completed suicides are rare. Such shortcuts in research methods lead to heterogeneity in the material, thus, complicating scientific and prognostic conclusions, more specifically regarding the risk for completed suicides later on. The stimulation of multi-centre studies could be a solution. Future research on self-harming behaviour should take into account gender specificity and other sociocultural differences as well as psychological and genetic factors in different types of self-harming behaviour, suicide attempts and completed suicides (Rutz 2004).

Conclusion

A high rate of male suicide is the most evident proof for males’ mental ill-being. When considering the links between men's individual depression and their suicidality a major challenge appears: the importance of improving the determinants and preconditions for men's well-being and health on a societal level. That is to say to identify and increase men's levels of autonomy, to counteract their helplessness, to facilitate a mutual and pluralistic gender tolerance, to support and resituate men's sense of social cohesion and existential meaning, and to provide a place for such traditional values of masculinity such as integrity, pride, status and dignity in modern societies of gender transition

In line with the World Psychiatric Association's new strategy of ‘psychiatry for the person’, improving the diagnoses and treatment of male depression is imperative. They should be directed to the male person taking into account the specific role expectations and weaknesses that are prevalent, such as sensitivity for change and status loss, and the often over-compensated inability to keep control and establish meaning and self-confidence in modern life. In order to do this, focus should be given to the overwhelming gender transitions across the world, that more or less stressfully affect both genders. Subsequently, one of the major suicide preventive and public health promoting strategies to perform in the near future is a positive interest for male-specific responses to stressful factors in societal change. Furthermore, an improvement of communication and a mutual interest of both genders with regard to the specificity of their respective circumstances is essential.

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                          Appendix 1

                          The Gotland Scale for assessing male depression (Rutz 1999)

                          During the past month, have you or others noticed that your behaviour is different than usual, and if so, in what way?

                          0 = not at all; 1 = to some extent; 2 = very true; 3 = extremely so

                          1. 1 Lower stress threshold/more stressed than usual.

                          2. 2 More aggressive, outward reacting, difficulty keeping self-control.

                          3. 3 Feeling of being burned out and empty.

                          4. 4 Constant, inexplicable tiredness.

                          5. 5 More irritable, restless and frustrated.

                          6. 6 Difficulty making ordinary everyday decisions.

                          7. 7 Sleep problems: sleeping too much/too little/uneasily, difficulty falling asleep/waking up early in the morning especially, having a feeling of disquiet/anxiety/displeasure.

                          8. 8 Over-consumption of alcohol and pills in order to achieve a calming and relaxing effect. Being hyperactive or blowing off steam by working hard and restlessly, jogging or practising some other form of sport, under- or overeating.

                          9. 9 Do you feel your behaviour has altered in such a way that neither you yourself, nor others can recognize you, and you are difficult to deal with?

                          10. 10 Have you felt, or have others perceived you as being gloomy, negative or characterized by a state of hopelessness in which everything looks bleak?

                          11. 11 Have you or others noticed that you have a greater tendency for self pity, to be plaintive or to seem pathetic?

                          12. 12 In your biological family, is there any tendency to abuse, depression/dejection, suicide attempts or proneness to some behaviour involving danger?

                          Points

                          0–13 No signs of depression

                          14–26 Depression possible. Specific therapy, including psychopharmacological, possibly indicated

                          27–39 Clear signs of depression. Specific therapy, including psychopharmacological, clearly indicated