The 12th leading cause of death overall in the US, suicide is a significant problem.1 In 2021, the death by suicide rate for men was four times the rate for women (22.8 versus 5.7 per 100,000); men comprise 80% of the total deaths by suicide in the US, although they comprise only 50% of the population.1 Unfortunately, there was a 4% increase in the number of suicides among men in 2021 from 2020.2 The first point of entry for identification and treatment of mental health problems is usually primary care settings, as they provide an ideal venue for identifying warning signs and risk factors for suicide. In one study, nonpsychiatric providers saw 45% of future suicide decedents within 30 days of suicide and 77% within 12 months of suicide.3 Therefore, it is important to provide primary care NPs the necessary tools and skills for preventing suicide.
Gender is an important aspect of identity; it is one of many social identities that influence how a man communicates and understands their masculinities.4 Therefore, it may be difficult to address mental health problems in men for several reasons. Although both men and women may present with typical symptoms of depression (sadness, anhedonia, fatigue, and difficulties with sleep), men may not report them as primary complaints.5,6 Rather, men might report more somatic symptoms, such as headaches, pain, fatigue, and gastrointestinal issues, as chief complaints, and/or they may cite irritability.6 In addition, men's depressive symptoms may be hidden by unhealthy coping styles used to avoid sharing emotions or addressing problems with others such as spending long hours working or exercising, engaging in risky behaviors, misusing alcohol or other substances, displaying inappropriate anger, or exhibiting violent, abusive behavior.5,6 For these reasons, depression in men often is unrecognized or underdiagnosed, resulting in failure to discern suicidal thoughts or plans and therefore missed opportunities to prevent death by suicide.4 Suicides may be preventable when the individual is appropriately identified as at risk, especially since these thoughts are often temporary. Primary care NPs are in an ideal position to identify warning signs and risk factors, screen for suicidal thoughts or plans, and refer patients to appropriate treatment in this population.
Warning signs, risk factors, and protective factors
It is important to differentiate between risk factors for suicide and warning signs of dying by suicide. Risk factors elevate risk; these factors can be more distant and long term (for example, genetics), or they can be more proximal (for example, precipitating or triggering events), whereas warning signs are changes in behavior or functioning that signal distress and increased risk of suicide in the near future.8 The primary care NP needs to be aware of both warning signs and risk factors of dying by suicide in men. In addition, it may be helpful for the NP to be aware of any protective factors, or existing conditions and attributes that mitigate risk, in treating this population. Protective factors may be present at the individual, relationship, community, or society level.
Warning signs. Warning signs for dying by suicide include withdrawing from family and friends; displaying dramatic mood changes; increasing alcohol and/or drug use; expressing suicidal thoughts; seeking out lethal means; expressing hopelessness, feeling stuck in life, or feeling that life has no purpose; and using covert statements indicating consideration of suicide, such as an individual saying that they are giving items or pets to others.7
Risk factors. Certain risk factors for suicide attempt or dying by suicide apply to all genders. There are also unique factors that contribute to suicide risk for men specifically.
For all genders, a family history of mental illness or suicide greatly increases an individual's risk for suicide.7,8 In addition, personal history of previous suicide attempts increases risk of death by suicide for all genders.9 Therefore, both family and personal history of suicide or suicide attempts should be collected as part of the individual's overall history.
Long-term experience of stress arising from occupational conflict, relationship problems, unemployment, lack of financial resources, legal trouble, harassment, rape, or bullying are identified risk factors for all genders.7,8 These external stressors may trigger debilitating emotions of despair, humiliation, or shame that contribute to isolation-another known risk factor-and to a belief that the individual is a burden to others.7
Chronic pain may be a significant risk factor for suicide in the US for all genders. It is theorized to be a contributing factor in the high rates of suicide among older adults.10
For men specifically, experience of childhood abuse or neglect confers higher risk.4 Reluctance to seek treatment for mental health conditions due to stigma also increases risk, as most suicides are linked to psychiatric illnesses.3 Alcohol use disorder and other substance use disorders, for example, have a significant association with death by suicide for men.4
Advancing age is a significant contributor to suicide risk for men. In the US, older adult males have the highest rate of suicide.7,11 Social isolation has been a factor associated with suicidal behaviors in middle-aged men.12 Role changes or major life events such as retirement, loss of a spouse, or loss of physical abilities may be especially challenging for men's identities and could lead to mental health problems or suicide.4,12 Management of chronic illness in primary care settings provides another compelling reason for screening.
Prior or current employment in male-dominated professions such as the military, law enforcement, and firefighting is associated with higher suicide risk.13
Access to lethal methods in the environment is a significant risk factor for death by suicide.8,14 The two most common suicide methods for men are highly lethal: firearms and hanging/suffocation.
Healthcare professionals are learning more about the impact of men's identities, including but not limited to ethnicity, gender identity, religion, socioeconomic status, mental health, disability, and sexuality, on health. Public health surveillance statistics on death by suicide that include adult men's identities are in early development.7 Establishing inclusive public health data is needed for intervention.
Protective factors. There are protective factors that can decrease the risk of dying by suicide. These include the ability to identify reasons to live (for example, children, family members, or friends), effective coping skills, certain religious and cultural beliefs (such as those that oppose suicide or encourage connecting with and seeking help from others), and the ability to identify existing connections with one's communities. A significant protective factor is lack of access to lethal means of dying by suicide.15 The NP can include this question in assessment of a patient expressing suicidal ideation: "What do you think has kept you from ending your life?" Answers to this question provide valuable information about protective factors; they also present an opportunity for the NP to highlight these reasons to the patient and to encourage the patient to use them as a source of strength.
Therapeutic communication
Primary care NPs practice cultural humility by avoiding stereotypes, performing self-examination of biases, partnering in treatment decisions, and being open to understanding each man's unique cultural perspective.16 It is important for NPs to be aware that men, depending on their understanding of their masculinities, may not state that they feel suicidal during a primary care visit even when they are, as there is stigma in society around mental health problems in men that may limit their disclosure. It is also important for NPs to know that asking their patients about suicidal thoughts and/or plans does not increase patients' suicide risk; therefore, raising these questions is not harmful, regardless of whether the individual is at risk, and, rather, can yield considerable benefit by presenting an opportunity to intervene.
In screening for and diagnosing depression or other mental health problems, NPs should move to "open the door" as much as possible for all men to feel comfortable with sharing their symptoms. Most depression screening scales (such as the commonly used Patient Health Questionnaire-9 [PHQ-9]) have an item that asks about suicidal thoughts; however, even if the patient indicates on the screening instrument that they are not experiencing suicidal ideation, it is still critical to ask about it directly. Before inquiring, the NP can state, "I ask all my patients this question," thereby allowing some normalization of the screening process and possibly increasing patients' willingness to share their thoughts. By asking directly about suicidal thoughts, paying close attention to patients' answers, and having caring conversations, NPs can encourage men to communicate more openly and develop connections with their providers, thus improving NPs' ability to provide required support.7
In engaging in these conversations with patients, NPs should be aware that terminology surrounding suicide has changed over the years. Current language aims to destigmatize suicide and suicidal thoughts, reduce judgment around having suicidal thoughts, and dismantle thinking that equates suicide with immorality and criminality. (See Suicide terminology for terms to avoid, the rationale for avoidance, and terms to use instead.)
Screening
In 2018, the National Action Alliance for Suicide Prevention (NAASP) published a guide describing recommended standard care for people at suicide risk; it contains recommendations for patient screening in primary care settings and is readily available online for NPs.17 At this time, experts who developed the report do not recommend universal screening for suicide in primary care; rather, they recommend that suicide risk be assessed for patients who present with key risk factors for suicide (for example, diagnosed mental health or substance use disorder, misuse of substances, or prescribed psychiatric medications).7,17
To assess risk for suicide, the NP can use the Ask Suicide-Screening Questions (ASQ).18 The tool was found to have a sensitivity of 100%, a specificity of 89%, and a negative predictive value of 100%.17 It contains four yes/no questions: 1) "In the past few weeks, have you wished you were dead?"; 2) "In the past few weeks, have you felt that you or your family would be better off if you were dead?"; 3) "In the past week, have you been having thoughts about killing yourself?"; and 4) "Have you ever tried to kill yourself?" If the patient answers any of the four questions with "yes," then providers should ask a final question: 5) "Are you having thoughts of killing yourself now?" If the answer to question 5 is "yes," then the man requires a full and immediate safety/mental health status evaluation and cannot leave until evaluated. In the primary care setting, this would require immediately contacting 911 to have the man escorted to the ED. If the answer is "no," a brief follow-up safety assessment to determine the need for a full mental health evaluation is recommended before the man leaves the office. The ASQ tool is available in 13 languages. The ASQ, follow-up safety assessment, and video instructions are available online.
Lethality assessment
If suicidal ideation is identified, evaluation of whether the man has plans to die by suicide and, if so, the details of those plans is essential for assessing the degree of risk. This is considered a lethality assessment. Elements of any lethality assessment include the following:
1) Does the patient have a specific plan to end their life with a date, place, or time frame?
2) How dangerous or high risk is the planned method? For example, using a firearm is more lethal than taking oral medications, as firearm use would entail rapid death and grant less time for potentially life-saving interventions.
3) Does the patient have access to the planned method?
Answers to these three questions reveal a person's risk level for dying by suicide. If a person has specific plans, particularly if they entail a high-risk or dangerous method, as well as access to the chosen method, then the individual is at high risk for dying by suicide.
The lethal means assessment is also recommended for patients with substance misuse or mental health disorders, even without active suicidal intent or ideation, when they are having problems with coping due to stressful circumstances. A crisis can escalate rapidly and lead to a suicide attempt that was not planned. For example, a person who is struggling with alcohol misuse and depression might impulsively choose to use a firearm or other means, if they are available, to end their life.
Suicide risk plan
In identifying a patient with suicidal thoughts and warning signs of dying by suicide, the NP's immediate plan must be to send the patient to the ED by calling 911. The NP can stress concern about the patient's safety as part of this conversation; however, the patient can be sent involuntarily for psychiatric evaluation. If a patient reports suicidal thoughts, it is important for them to inform family members or friends about these thoughts or to allow the NP to contact and inform them. If the patient does not allow the NP to contact family and/or friends or if the patient lives alone, then it becomes even more critical to send the patient immediately to the ED for psychiatric evaluation due to an increased risk of dying by suicide related to lack of social support.12
Safety plans. Discussions with family members and/or friends could help with developing a safety plan. Safety plans are formulated preemptively to give patients options for staying safe upon experiencing suicidal thoughts. The NAASP guidelines for primary care settings recommend that providers assist patients with development of a brief safety plan at the time suicidal ideation is identified. Additionally, the NAASP recommends two brief follow-up caring contacts (conversations or messages that impart caring, support, and connection) within the week after the visit at which suicidal ideation is identified. Using the Safety Planning Intervention tool, a safety plan can be written on paper or entered into an app through a mobile device. The Safety Planning Intervention provides all the necessary components to create an effective safety plan, including 1) warning signs (thoughts, feelings, and behaviors that trigger suicidal thoughts), 2) internal coping strategies (how men can cope with these feelings), 3) distractions, activities, and positive environments (to take one's mind off of distress by doing other activities or spending time with a particular person), 4) people to ask for help (those who know about suicide risks), 5) professionals/providers and organizations to ask for help (therapist, mental health provider, the 988 Suicide and Crisis Lifeline, and the ED), and 6) ways to make the environment safe and clear of lethal means.7
Lethal means counseling. Research has shown that, in addition to safety planning, removing access to chosen means for suicide saves lives. The Suicide Prevention Resource Center recommends counseling about lethal means for patients and families.19 As suicidal crises are hard to predict and often brief, lethal means counseling needs to occur before a suicidal crisis. This counseling is recommended in three types of patient presentations: 1) those with current suicidal ideation; 2) those with past suicidal behaviors and active distress; and 3) those who present with struggles of substance misuse or diagnosed mental health disorders.
The primary care NP can discuss lowering access to lethal means in the home for men who are deemed to be at risk. Firearms are used in the majority of deaths by suicide among men. Safe storage of firearms until the patient recovers is an important goal.19 Planning for this storage is best done in collaboration with the male patient, their family, and/or their significant others. Temporarily storing firearms away from the home is safest. However, there are federal and state laws that govern transfer of firearms among individuals. Primary care NPs need to be aware of any legal barriers to the temporary transfer of firearms in their practice state. Second-choice options are to lock up firearms (unloaded and with ammunition in a separate location) in a safe or lockbox with the key stored outside the home if possible or to disassemble the guns and store firing pins away from the home. Counseling on Access to Lethal Means (CALM) is an award-winning online educational course designed for healthcare professionals that has free handouts to aid providers in developing a guiding, collaborative approach to counseling patients in reducing access to lethal means.19
Medication considerations. Primary care NPs who treat depression and/or anxiety disorders in men must consider the lethality of any medications they might consider prescribing. Though not commonly used for mental health treatment in primary care, tricyclic antidepressants (TCAs) can cause cardiac arrest and death when consumed in high amounts. If a man at risk for suicide is taking TCAs for other indications (such as chronic pain or migraines), the prescription quantity should be limited to no more than what is needed for 2 weeks. Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors are relatively safe, but it is still important to limit prescription quantity. Hypnotics and benzodiazepines should not be prescribed. It is critical to be aware of substance use problems that can increase the likelihood of dying by suicide through decreasing one's inhibitions. Frequent follow-up appointments (for example, every 1 to 2 weeks) after initial prescription of pharmacologic therapy for depression are recommended for all patients to further assess for suicidal thoughts. (See Suicide risk assessment in primary care for an overview of risk assessment.)
Another strategy is to include family members in reducing access to medications if an identified potential method of suicide for the patient is to take a lethal amount or combination of pills; family members might choose to keep only small amounts of over-the-counter medications (for example, acetaminophen) available and possibly lock up other medications, except for certain emergency drugs such as epinephrine injections for treatment of allergic reactions (EpiPens) and inhalers.
Referral
If at any time the primary care NP is concerned after assessment that a male patient exhibiting suicidal thoughts is not safe to return home or is at imminent risk of death by suicide, or if a patient displays warning signs of suicide, the priority is to send him to the ED by calling 911. The individual may need intensive treatment, such as inpatient or partial hospitalization, for his safety. If a man is expressing suicidal thoughts but the primary care NP determines after a thorough assessment that he is not at imminent risk of suicide and is safe to return home, it is important to refer him to a psychiatric provider for treatment. Psychiatric providers have expertise in treating complex mental health problems, and men who are suicidal need this type of care. Male patients may be hesitant to accept specialty care, depending on their experiences of their masculinities. Therefore, it is recommended that primary care NPs discuss with men the reasons for the referral and express concern for their safety. Again, normalization of mental health care may be beneficial for men. If there are difficulties with referring men to treatment due to a lack of providers in their area, it is helpful for primary care NPs to develop connections with psychiatric NPs and/or psychiatrists to assist in treatment referral. (See Clinician and patient resources for addressing suicide risk in men.)
Conclusion
Suicide can be prevented through clinical interventions and family support. NPs play a role in identifying men who present with suicidal risk factors and warning signs. Identifying high-risk individuals, asking about suicidal thoughts, assessing safety, and making appropriate referrals to psychiatric providers and/or emergency care can decrease the incidence of deaths by suicide in this population.
REFERENCES