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Suicide in Men

Leo Sher, MD

Published: March 25, 2015

See Article by Ishii et al.

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Suicide in Men

An interesting and important article, “Low Risk of Male Suicide and Lithium in Drinking Water,” is published in this issue of The Journal of Clinical Psychiatry.1 The authors found that lithium levels in drinking water were significantly and inversely associated with male suicide standard mortality ratios (SMRs) but not total or female SMRs. This observation reminds us about the complex issue of gender differences in suicidal behavior.


While women show higher rates of reported nonfatal suicidal behavior, men have a much greater rate of completed suicide.2-4 Worldwide, men commit suicide 3-10 times more frequently than women.2,3 Male suicide rates are higher than female rates at all ages. In the United States and Canada, men die from suicide attempts 3 times more often than do women.3,4 The gender-suicide gap is especially large in some European countries such as Hungary, Lithuania, Latvia, Belarus, and Ukraine.5


Multiple psychosocial factors may contribute to the observed gender differences in suicidal behavior. The traditional male gender role is described by characteristics such as independence, aggressiveness, risk-taking behavior, pursuit of power and dominance, competitiveness, success, and control.2,6-9 The male gender role in Western cultures implies not acknowledging anxiety or depression, which might arise under difficult or threatening conditions.

The susceptibility of many men to suicide is probably related to their relative unwillingness to get help when they are distressed.2,6-10 A review of help seeking by persons who committed suicide revealed that men had lower overall rates of contact with health care providers compared with women.10 This study showed that in the year before suicide, 58% of women versus 35% of men sought care from a mental health professional. Men’s lack of help seeking may be partially related to a lack of training and responsiveness from some psychiatrists and other clinicians who may not treat depressed, anxious, or suicidal men empathically.2

Suicidality in men is considerably affected by socioeconomic aspects such as income, wealth, employment status, and social position.2,6-9,11 Men’s susceptibility to suicide may be increased in periods of unemployment because of gender anticipations that men should support themselves and their families. Also, unemployment is frequently associated with poverty, domestic difficulties, depression, and hopelessness, which all may contribute to suicidality.

Studies have shown that the association between alcohol/drug abuse and suicide is more significant for men, and many more men than women use alcohol/drugs immediately prior to their suicide.7,9,12 In many societies, alcohol use is associated with masculinity, and this may explain a connection between alcohol use and suicide in men.7 Alcohol may be consumed by some men to lessen depression or anxiety and as an unhealthy alternative to getting professional help for psychiatric issues.

Marital breakdown leads to many difficulties for men, including the possibility of parental alienation from children.13,14 Fathers who have lost some or all contact with their children for months or even years following separation or divorce are sometimes in a severe suicidal crisis since the loss of contact or restriction of the relationship between the children and the father is a very traumatic and distressing experience for both the children and the father.


Neurobiological gender differences may play a substantial role in the differences in suicide rates between men and women. As noted above, an article in this issue of The Journal of Clinical Psychiatry suggests that lithium may decrease suicide rates among men but not among women.1 This finding may indicate that lithium affects men differently than women.

Impulsivity and aggression have been associated with death by suicide and are among the most frequently implicated risk factors for engaging in suicidal behavior.15,16 It has been observed that lithium administration decreases impulsive aggressive behavior in men.17 Possibly, higher levels of lithium in the drinking water decrease suicide rates among men by reducing impulsivity and aggression.

Another possible hypothesis is related to a potential role of testosterone in suicidal behavior. We observed that higher testosterone levels were associated with higher suicidality.18,19 Testosterone levels are much higher in men than in women.20 An adult male body produces approximately 10 times more testosterone than an adult female body. Several research studies demonstrated that the administration of lithium reduces testosterone levels.21,22 It is interesting to speculate that lithium reduces suicidality in men by decreasing testosterone levels.


Suicide is a significant contributor to death in men. We need to develop reliable approaches to diagnose depressed and suicidal men and to help them and ourselves to overcome unrealistic male role expectations. There is a need for more research to develop suicide preventive strategies on the basis of reliable knowledge.

Author affiliation: James J. Peters Veterans Administration Medical Center and Icahn School of Medicine at Mount Sinai, New York, New York.

Potential conflicts of interest: None reported.

Funding/support: None reported.


1. Ishii N, Terao T, Araki Y, et al. Low risk of male suicide and lithium in drinking water. J Clin Psychiatry. 2015;76(3):319-326.

2. Rutz W, Rihmer Z. Suicidality in men: practical issues, challenges, solutions. J Mens Health Gend. 2007;4(4):393-401. doi:10.1016/j.jmhg.2007.07.046

3. Nock MK, Borges G, Bromet EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30(1):133-154. PubMed doi:10.1093/epirev/mxn002

4. Bilsker D, White J. The silent epidemic of male suicide. B C Med J. 2011;53(10):529-534.

5. WHO mortality database. Updated July 2014. Accessed September 10, 2014.

6. Murphy GE. Why women are less likely than men to commit suicide. Compr Psychiatry. 1998;39(4):165-175. PubMed doi:10.1016/S0010-440X(98)90057-8

7. Möller-Leimkühler AM. The gender gap in suicide and premature death or: why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci. 2003;253(1):1-8. PubMed doi:10.1007/s00406-003-0397-6

8. Schrijvers DL, Bollen J, Sabbe BG. The gender paradox in suicidal behavior and its impact on the suicidal process. J Affect Disord. 2012;138(1-2):19-26. PubMed doi:10.1016/j.jad.2011.03.050

9. Payne S, Swami V, Stanistreet D. The social construction of gender and its influence on suicide: a review of the literature. J Men’s Health. 2008;5(1):23-35. doi:10.1016/j.jomh.2007.11.002

10. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909-916. PubMed doi:10.1176/appi.ajp.159.6.909

11. Sher L. Per capita income is related to suicide rates in men but not in women. J Mens Health Gend. 2006;3(1):39-42. doi:10.1016/j.jmhg.2005.04.016

12. Bilban M, Skibin L. Presence of alcohol in suicide victims. Forensic Sci Int. 2005;147(suppl):S9-S12. PubMed doi:10.1016/j.forsciint.2004.09.085

13. Johnston JR. Parental alignments and rejection: an empirical study of alienation in children of divorce. J Am Acad Psychiatry Law. 2003;31(2):158-170. PubMed

14. Von Boch-Galhau W. Parental Alienation and Parental Alienation Syndrome/Disorder. English Edn. Berlin, Germany: VWB-Verlag fur Wissenschaft und Bildung; 2013: 168.

15. Gvion Y, Apter A. Aggression, impulsivity, and suicide behavior: a review of the literature. Arch Suicide Res. 2011;15(2):93-112. PubMed doi:10.1080/13811118.2011.565265

16. Oquendo MA, Mann JJ. The biology of impulsivity and suicidality. Psychiatr Clin North Am. 2000;23(1):11-25. PubMed doi:10.1016/S0193-953X(05)70140-4

17. Sheard MH, Marini JL, Bridges CI, et al. The effect of lithium on impulsive aggressive behavior in man. Am J Psychiatry. 1976;133(12):1409-1413. PubMed

18. Sher L, Grunebaum MF, Sullivan GM, et al. Testosterone levels in suicide attempters with bipolar disorder. J Psychiatr Res. 2012;46(10):1267-1271. PubMed doi:10.1016/j.jpsychires.2012.06.016

19. Sher L, Grunebaum MF, Sullivan GM, et al. Association of testosterone levels and future suicide attempts in females with bipolar disorder. J Affect Disord. 2014;166:98-102. PubMed doi:10.1016/j.jad.2014.04.068

20. Shahidi NT. A review of the chemistry, biological action, and clinical applications of anabolic-androgenic steroids. Clin Ther. 2001;23(9):1355-1390. PubMed doi:10.1016/S0149-2918(01)80114-4

21. Thakur SC, Thakur SS, Chaube SK, et al. Subchronic supplementation of lithium carbonate induces reproductive system toxicity in male rat. Reprod Toxicol. 2003;17(6):683-690. PubMed doi:10.1016/S0890-6238(03)00107-2

22. Ghosh PK, Biswas NM, Ghosh D. Effect of lithium chloride on testicular steroidogenesis and gametogenesis in immature male rats. Acta Endocrinol (Copenh). 1991;124(1):76-82. PubMed

Submitted: September 29, 2014; accepted October 8, 2014.

Corresponding author: Leo Sher, MD, James J. Peters Veterans Administration Medical Center, 130 West Kingsbridge Rd, New York, NY 10468 (

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