What is evident from a survey of the literature, is that feelings of isolation, alienation, helplessness and hopelessness can be identified as possible 'causes'. William Glasser, the father of Reality Therapy argues that everyone who needs psychiatric treatment suffers from one basic inadequacy: they are unable to fulfill their essential needs. He expands on the essential needs as being the need to love and be loved and the need to feel that we are worthwhile to ourselves and to others. It is the pain that results from these emotional needs not being met (regardless of the cause), the feelings of isolation, alienation, helplessness, hopelessness, worthlessness, anxiety, stress, despair, rejection and failure which form the essence of the emotional pain experienced by the suicidal person. Shnei deman describes this emotional pain as 'psychache'. 27

SUICIDE AS PSYCHACHE
After working in this field for over 50 years Shneidman says:
Nearing the end of my career in suicidology, I think I can now say what has been on my mind in as few as five words: Suicide is caused by psychache. Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind. It is intrinsically psychological - the pain of excessively felt shame, or guilt, or humiliation, or loneliness, or fear, or angst, or dread of growing old, or of dying badly, or whatever. When it occurs, its reality is introspectively undeniable. Suicide occurs when the psychache is deemed by that person to be unbearable. This means that suicide also has to do with different individuals thresholds for enduring psychological pain. 28

Suicide in 1998: An Overview
1997 and 1998 Statistics Compared

Figure 1: Age-specific suicide rates 1997
Rate per 100,000 persons

Source: Australian Bureau of Statistics (1999). Suicides: Australia 1921-1998. 1997. Canberra


Figure 2: Age-specific suicide rates 1998
Rate per 100,000 persons

Source: Australian Bureau of Statistics (1999b). Suicides: Australia 1921-1998. 1997. Canberra


Observations: Comparing age specific suicide rates in 1998 with 1997

Source: Australian Bureau of Statistics (1999). Suicides: Australia 1921-1998. 1997. Canberra

1997 and 1998 Suicide Numbers Compared (States and Territories)

Observations

• Youth (15-24) suicide decreased in most states

Victoria saw the most significant decrease in young male suicide, but this was accompanied by in increase in young female suicide.

Western Australia experienced a significant increase in youth suicide.

• Male (25-44) suicide increased in most states

Most significant increases in NSW, Qld, SA, WA and Tas.

ACT and Vic were the only 2 states to see decreases.

• Female (25-44) suicide numbers increased significantly in Qld and SA.

TRENDS IN SUICIDE RATES
Statistics show that in the range of 10 - 14 suicides per 100,000 people, Australia's suicide rate has been reasonably stable since the 1920s. However, increases have occurred in specific age groupings.

Some trends are obvious: fluctuation rates during the two world wars, the 1930s economic depression and the significant increase of female suicides during the 1960s, which has been attributed to the increased accessibility of barbiturates and new drugs. Following a campaign targeted to educate practioners, prescribing patterns were regulated with increased control and the female suicide rates declined.

Trends among selected groups

Youth Suicide
When comparing age groups, the biggest increase in deaths from suicide over the period 1921 to 1988 has been in the 15-24 years age group (approximately 6 per 100,000 in 1921 to 17 per 100,000 in 1998). Increased suicide rates in this group, particularly among young males, began in the late 1960s with a sharp increase in the 80s and 90s, peaking in 1997, when Australia recorded the highest youth suicide rate among industrialised countries. In 1998 youth suicide saw a decrease of 64 deaths, dropping the age-specific rate from 19.1 in 1997 to 16.7 in 1998.30

Middle-aged Suicide:In 1998:

• Nearly 24 per cent were by people aged 20 to 29
• More than 25 per cent were by people aged 30 to 39
• About 17 per cent were by people aged 40 to 49
• About 27 per cent were by people aged over 50
• About 12 per cent were by people aged over 65; and
• Less than 6 per cent of suicides were by people aged under 20.31

There has been an overall increase in rates among persons aged 25-44. In 1921 the age-specific rate for this age group was approximately 15 per 100,000, as compared to 20 per 100,000 in 1998. This group has the highest age-specific suicide rate among all age groups. Within this group the majority of the increase occurred in male suicide rates - the focus group of this report.

Aboriginal Suicide

Professor Colin Tatz, the author of the most comprehensive study on Aboriginal suicide in Australia, notes that it has only been in recent times that suicide has emerged as an issue among Aboriginal communities.33 A review of Aboriginal history suggests that

"suicide was an alien concept in Aboriginal life" It was never mentioned by Aboriginals, anthropologists, linguists, government officials, missionaries, magistrates, pastoralists or police. In 1968, Kidson and Jones found an absence of 'classical neuroses psychosomatic illness and suicide' among Western Desert people. John Cawte's medico-sociological expedition to Arnhem Land in 1968 found 'nothing alarming' about Aboriginal suicide rates? Hunter-Reser et al state that 'some three decades ago the suicide of an Indigenous Australian was a rare occurrence'.34

While the collection of data, specific to suicide rates by race of origin has only been a recent initiative by relevant state bodies, with information on Aboriginal peoples unreliable, it appears that suicide rates have increased considerably over the past two or three decades.37

Between 1 January 1996 and 30 June 1998, 43 Aboriginal suicides were reported in NSW and the ACT alone, which equates to 40 suicides per 100,000 Aborigines per year.38 There were a further 31 suicides in that period amongst those of uncertain Aboriginality. If they were, as is suspected, Aboriginal suicides, then the rate would be much higher. Tatz suggests that "if the Australian figures are even reasonably accurate, Aboriginal rates are possibly two to three times the non-Aboriginal.39

Despite the limited amount of research on Aboriginal suicide, most Australian commentators acknowledge that this is a relatively recent trend, which needs to be addressed immediately and addressed as an issue different to non-Aboriginal suicide.

"Aboriginal suicide has unique social and political contexts, and must be seen as a distinct phenomenon."40

It is recognized that indigenous issues cannot all be solved by non indigenous individuals and organisations. However, that is not to say that external assistance is unwelcome, or unnecessary, and improved resources and materials for professionals working with indigenous Australians would enable us to better understand and respond to their particular needs and problems.41

Gay and Lesbian Suicide
Although the issue of suicide has been recognised as a problem from within the gay and lesbian community, it has only recently attracted some media and government attention. While research in this area is very scant, the idea that gay men, lesbians and bisexual people are at an increased risk for suicide is not new. Havelock Ellis' Sexual Inversion, first published in the late 19th century noted that homosexual men "frequently commit suicide"42

Kent Fordham, in his study on Sexuality & Suicide argues that
"Anecdotal evidence of the phenomenon of suicide among gay men and lesbians has, then, been around for at least a century. Despite this, very little research was conducted in the field until the past decade. Rather than being due to lack of interest in the area, the paucity of research was more likely due to the stigma surrounding homosexuality. Homophobia permeates all levels of society, and it is not surprising that potential researchers would have avoided the area, for fear of damaging their reputations or careers."43

Recent studies in the USA and Canada suggest that homosexuality issues are involved in up to one third of young men under 24 who suicide. A recent Australian study replicates these findings. In his study for the US Department of Health, Gibson states that

"Suicide is the leading cause of death among gay male, lesbian bisexual and transsexual youth? Gay males were six times more likely to make an attempt than heterosexual males. Lesbians were more than twice as likely to try committing suicide than the heterosexual women in the study. A majority of the suicide attempts by homosexuals took place at age 20 or younger, with nearly one-third occurring before age 17."45

Several recent studies have shown that gay, lesbian and bisexual people, particularly adolescents and young adults, are at substantially increased risk of suicidal behaviours and suicidal thinking. For gay, lesbian and bisexual young people (up to age 27), studies in the United States have found risk of suicide attempt ranging from 3.5 to nearly 14 times that experienced by heterosexual young people.

A recent Australian study found that gay-identified young men (aged 18 - 24) were 3.7 times more likely to attempt suicide. Most of these attempts occurred after the person had self-identified as gay, but before having a same-sex experience and before publicly identifying themselves as gay.46

Overall, studies of completed suicides have not found gay youth over-represented, however, studies focused on suicidal ideation and suicide attempts show significantly higher rates among gay and lesbian youth compared to heterosexual youth.47

Rural And Remote Communities
It is only since 1998 that data disaggregated by capital cities, other urban and rural locations has become available.

The past 10 years have seen a higher rate of suicide amongst males in rural and remote areas than in urban areas.

Throughout the 10 year period, 1988 to 1998, rural areas had the highest rates of suicide ranging from 14.6 to 17.1 per 100,000 persons, while other urban areas had the next highest rates of suicide ranging from 14.7 to 14.9 per 100,000 persons, and capital cities had the lowest rates ranging from 12.8 to 12.9 per 100,000 persons.48

In 1998, the Northern Territory recorded the highest suicide rate, at 21 per 100,000 persons. This was followed by Queensland and South Australia at 16 per 100,000; Western Australia at 15 per 100,000, New South Wales, 13 per 100,000, Tasmania and Victoria at 12 per 100,000 and the ACT at 9.5 per 100,000.49

Whilst suicide rates for males have increased in metropolitan areas, the most significant increases have been in communities with populations of less than 4,000.50

Economic and social change in Australia, particularly in the last 30 years have had a dramatic impact on farming and rural areas. In some cases, whole communities have suffered economic hardship and many are struggling to survive. Indeed, it is widely accepted that small communities, with populations of less than 10,000 are no longer economically viable, as we witness farm repossession, business and industry closures, the removal of medical and educational services, and the exodus of people to larger commercial centres.51

Such drastic changes have taken their toll on the people in farming communities, whose already high sense of alienation and isolation is exacerbated by financial insecurity and family breakdown.

A further factor is the availability of guns in rural areas. Whilst restrictive gun laws have seen a decrease in gun related incidences of suicide and self harm in general/in metropolitan areas, this has not been the case in rural Australia where guns are commonplace.

A comprehensive study of male suicide in Victoria presented to the National Conference for Suicide Prevention, highlighted the effects of social disadvantage on the health of many young men in rural communities in the state. It found that those young men with lower levels of education were grossly over represented in suicide rates. Moreover, funding for suicide prevention services had targeted schools and mental health services. Given that the majority of young men committing suicide were neither in school, nor in a position to seek medical help, prevention efforts were not reaching those most in need.54

Middle-Aged (25-44) Male Suicide
Statistics at a Glance

• 80% of suicides in 1998 were committed by men, a total of 2,150.55
• More men are killing themselves than are dying in road accidents.56
• Men aged 25-44 made up about 40% of total suicides for 1998.
• The number of suicides by men aged 25-44 has risen by 44% since 1979.57

Throughout Australia's history, males have always committed suicide at greater rates than females even though females have traditionally attempted suicide at greater rates than men.55 Whereas long term trends show a relatively stable incidence of female suicide in Australia, the picture for men is substantially different. In fact, the rise in suicide in recent years is almost wholly attributable to an increase in male suicide.

Men of all age groups in Australia are far more likely than women to die from suicide, with 1998 rates at 23 per 100,000 men (2,150 deaths) compared with 5.7 per 100,000 women (533 deaths). Rates for men have been consistently higher than for women throughout the time Australian data have been collected.58

In recent times, there has been a strong emphasis on male youth suicide, both in the media and in funding from government bodies. The under 20 age group was seen as the most 'at risk', and initiatives developed which addressed youth issues and youth suicide.

An analysis of the most recent Australian Bureau of Statistics suicide rates by the Australian Institute for Health and Welfare dispels the widely held belief that suicide is primarily a problem among Australian youth. Their findings show that the rise in male suicide has been almost entirely due to an increase in the rates for males aged over the age of 20. Men in the 20-39 year age group now have the highest suicide rate. In a surprising contrast, the rates of male teenage suicide are much lower than for all other age groups.

Moreover, the number of suicides among older age groups can be expected to rise, given that they constitute the fastest growing segment of the population.60

Suicide rates reach a second peak in older men over 85 years, with rates at 31.8 per 100,000. It may be that older men find themselves for the first time, physically and economically dependent, or affected by mental and physical health problems. Other treatable factors identified as contributing to suicide in old age include pain, grief, loneliness, alcoholism and carer stress.

How do we explain this changing trend?

What is often hidden by conventional statistical reporting methods is that youth suicide is no longer the problem that it once was. Instead, what we are seeing is a 'generational' tendency towards suicide. Men who were part of the youth suicide trend from the late 1970s are now reaching 'mid life' - and they continue to commit suicide at a rate far higher than their younger counterparts. In fact, the number of suicides for men between the ages of 25 and 44 has risen 44% since 1979.61

By breaking down the 1998 data into smaller age groupings, we find that for men aged 25-29, 30-34 and 35-39, suicide rates were at an all time high.

Our tendency to focus on suicide amongst young people, and particularly males, has profound implications, not only for suicide prevention initiatives, but also for how we as a community view the whole issue of suicide. 'Youth suicide' somehow seems easier to grasp, linked as it has been with high levels of unemployment, family break-down and a general perception that the youth in our society were more prone to anti-social behaviour. On the other hand, suicide amongst an age group widely perceived as being more stable, both financially and emotionally turns this assumption on its head, and challenges the foundations of many of our approaches to the issue of suicide in general.

This has profound implications for Prevention Initiatives, which have tended to focus campaigns at younger age groups, and school education programs in particular. We cannot hope to make any impact on the increasing suicide rates while we still insist on focusing on young people, and ignoring the problems of middle aged men.

Factors Influencing Suicide in Older Men.

MALE HEALTH
Until fairly recently, male health has been a much neglected issue. Women typically are much more interested in their health, evidenced by the higher numbers of women who use Medicare services. Women's health issues have, at least since the 1960s, been widely discussed in the public domain and women are well represented in health industries.

For men, however, it is a different story. Men are far less likely to visit their GP, or to seek medical advice. This, despite evidence that men participate in 'health risk behaviours' to a much greater extent. It has been argued that certain aspects of men's socialised behaviour have a major impact on their health risk.

'Excessive competition, unrealistic and unattainable models of masculinity, poor self-esteem, lack of meaningfulness, poor identity formation and a lack of sustainable role models are some of the culprits that have left men in their teens, early twenties, after the age of 45 and after retirement feeling they have reached their use-by date.'62

Whilst a higher rate of mental disorder is typically associated with women, there is increasing evidence to suggest that men in fact may suffer depression and other forms of mental illness as much, if not more than women.63

Moreover, men respond differently to stressful and emotional events in their lives. Whilst women may show a high level of depression and anxiety, men are more likely to resort to substance abuse.64

When we examine the statistics, men's problems become painfully obvious. Huggins states:

• Our prisons are full of men (90%), they are not full of women (10%);
• Our juvenile detention centres are full of boys, not girls;
• Approximately 90% of our school suspensions and expulsions are boys, not girls;
• Our remedial reading classes are full of boys, not girls;
• Well over 80% of our drug and alcohol abusers are boys and young men, not girls and young women;
• The rate of suicide in the 15-24 year age group for males is nearly seven times the rate for females in the same age group;
• Injury rates for males are three times the rate for women;
• The perpetration of violence and abuse is approximately 95% male.65

Mental Health/Depression

The issue of male suicide in the middle-aged group was made more public earlier this year following the suicide death of a prominent Labour MP in his early forties, who had been suffering from depression following his marriage break-up. This tragic suicide shocked the Australian community, a community so accustomed to hearing that suicide was a 'youth issue'. Why would a man, at his stage in life, take his own life?

This death highlighted the very real problem of depression amongst men in general, and its links to male suicide in particular.

There is strong evidence that mental health problems are major contributors to suicidal behaviours in people of all ages. Various studies, both in Australia and overseas have shown that more than 90% of people who committed suicide were suffering from some form of mental illness. This was the case across all age groups. Indeed, people with recognised mental illness are 10 times more likely to take their own lives than the general population.66 It has also been estimated that 15% of people suffering serious mental illness will eventually commit suicide.67 Sufferers of schizophrenia are particularly vulnerable, with up to 10% taking their own lives.68

It is quite clear that having a mental disorder places a person, whatever their age, at considerably higher risk of suicide than the general population. One of the most common forms of mental illness associated with suicide is depression. Suicide rates are higher for people who are not receiving treatment for depression, or whose current treatment is not effective. There is strong evidence that appropriate pharmacological treatment can dramatically reduce the risk of suicide in people with depression and schizophrenia, and for adults with bipolar disorder.69

A 1997 report by the Australian Bureau of Statistics into mental health estimated that only 25% of people believed to be suffering from depression were actually receiving adequate treatment.70

"We are extraordinarily bad at recognising depression in men," claims Graham Martin, the national chairman of Suicide Prevention Australia. "Men don't go to doctors and when they do they are often patted on the shoulder and told, 'Don't worry, mate.' Men don't tell anyone at work their problems. Instead, they might start drinking, get violent or do something impulsive like suicide."71

While any person with a mental disorder is potentially more vulnerable to suicide, there is particular need for vigilance with depressed older men.

The World Health Organisation has warned that depression will escalate from the fourth-greatest cause of death to the equal-biggest cause in the Western world by 2020. Mounting an attack against depression, defeatism and disillusionment will not be easy, because modern Western culture is not well equipped. Its hallmarks - such as individualism, secularism, liberalism, intellectualism, materialism, consumerism and economic rationalism - may be lauded as its strengths, but equally may prove to be its greatest liabilities when it comes to establishing sound mental health among the population.72

Perhaps the MP's own words can shed some light on the issue. In a speech made to Federal Parliament in 1997, he said that '...people have a strong desire to feel needed, to feel that they are loved, and to feel that they have some worth and role in life. [?] men kill themselves due to an inability to cope with life events such as relationship break-ups, ? and unemployment."73

He concluded by saying 'There is certainly a need for our community to work towards an environment in which people feel a sense of belonging and meaning.[?] If we can achieve such a state, then the incidence of all suicides [?] will no doubt be reduced. [?] if we can tackle some of the fundamental problems in society, such as the quality of education, unemployment and job security, there will no doubt be a flow-on to reduced family breakdowns, and ... fewer suicides.'74

Marital Status

Interestingly, marriage seems to 'protect' people from suicide. Married people show lower suicide rates than those who have never married, or who have been divorced.75

Recent research into male suicide in this age group revealed that males in the 'separation phase' of a marriage break-up were most at risk of suicide, compared with widowed or divorced males.76 Whilst these are only preliminary findings, they suggest that the severe disruption of separation and the high levels of interpersonal conflict that were associated with it, were perhaps the greatest contributing factor, along with separation from children.

Marriage breakdown is a significant characteristic of male suicide in the 24-39 age bracket. The anxiety and emotional pain of separation and divorce appear to effect men differently.

Whilst suicides may simply be recorded as statistics, it is the increasing number of murder/suicides, involving children that have brought the tragic reality of male suicide, and male mental health issues in general into the public arena.

Where children are concerned, there is evidence to suggest that many men sense they are being discriminated against in Family Court judgements, and often find themselves in financial straits having to pay legal fees and child support payments. The difficulty in maintaining access to children also heightens the frustration and isolation of separated and/or divorced men.77

Following two murder/suicides in Western Australia in 1999, where fathers gassed both themselves and their children to death, Allan Huggins, director of Men's Health, Teaching and Research at Curtin University, said "There is a whole range of psychological issues for them to deal with, but ultimately they see their situation as being totally hopeless and then a realm of fantasy begins where they want to take their children with them to what they perceive as being a better place."78

It seems that 'stressed fathers will keep killing'79 both themselves and their children, until adequate support services are provided.

Professor Pierre Baume, Head of the Australian Institute for Suicide Research and Prevention at Griffith University in Queensland found that, in a study of 4,000 suicides, at least 70% were associated with relationship break-ups. Men were 9 times more likely to take their own lives following break-up than women.80

Why do men and women respond so differently to separation?

Research suggests that the majority of divorces are initiated by women, and that in most cases, married men did not want to separate and had tried to resolve the problems.81 Further evidence suggests that the period of 'separation' is one of the most stressful times in a man's life, and often this anxiety and frustration continues for many years.82 Moreover, men are not inclined to access relationship services, or to seek advice and support when they are in times of need.

Epidemiological studies show a strong correlation between divorce and separation, and mental health problems.83 Alcoholism and depression are much more common in those who have experienced relationship breakdown. Whilst it is not clear whether depressed people, or alcoholics are predisposed to relationship problems leading to suicide, or that these symptoms come about following, and as a result of relationship breakdown, there is no doubt that men in particular are at risk.

The Howard Government has acknowledged the problem of male suicide, particularly following relationship break-ups. It has agreed to fund a $16.5 million initiative focusing on men and family relationships. With the state governments, it continues to fund the Labor initiated mental health strategy.84

Substance Abuse

Alcoholism in Australian is a major public health problem, and is far more common in men than women.85 It has been estimated that 33% of males suffer symptoms of alcoholism at some point in their lives, compared with only 5% of women.86

Alcohol abuse, particularly when combined with other factors, is characteristic of a high proportion of adult male suicide deaths.87 Researchers have shown that approximately 15% of alcoholics die by suicide, most occurring between the ages of 40 and 59.88 The majority of these are male.

Use of illicit drugs is less common than alcoholism, but shows similar trends, affecting approximately 6% of men, compared with only 1% of women.89 Heroin addiction, in particular, is associated with higher rates of suicide. However, it is often very difficult to determine whether death was as a result of suicide, or accidental overdose, and coroners are more likely to give the cause of death as accidental overdose rather than suicide, because of the stigma attached to suicide.

Victoria's Suicide Prevention Task Force has emphasised that substance abuse, violence, depression and access to means are a deadly combination in men.90

Unemployment and underemployment

When we examine the suicide trends in Australia throughout the last century, there appears to be quite a distinct correlation between unemployment and suicide. In periods of high unemployment, such as during the Depression, suicide rates soared.

Underemployment is also a factor, with those at the 'lower status' end of the labour market, whose employment offered 'low job autonomy, greater external supervision, less on-the-job training, poorer promotional possibilities, lower wage levels and greater sensitivity to market forces'91 had suicide rates very close to twice that of those in 'higher status' employment, with a steady decline in suicide as occupational.

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